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The journal of mental science.

London : Longman, Green, Longman & Roberts, 1859-1962.

http://hdl.handle.net/2027/nj p.32101074924513

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PRINCETON UNIVERSITY

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PRINCETON UNIVERSITY

THE JOURNAL

MENTAL SCIENCE.

EDITORS:

J. R. Lord, C.B.E., M.B. Henry Devine, O.B.E., M.D.

G. Douglas HoRae, M.D.

W. R. Dawson, O.B.E., M.D.

VOL. LXVI.

J. & A. CHURCHILL,

7, GREAT MARLBOROUGH STREET.

MDCCCCXX.

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PRINCETON UNIVERSITY

" In adopting our title of the Journal of Mental Science, published by authority
of the Medico-Psychological Association, we profess that we cultivate in our pages
mental science of a particular kind, namely, such mental science as appertains
to medical men who are engaged in the treatment of the insane. But it has
been objected that the term mental science is inapplicable, and that the term
mental physiology or mental pathology, or psychology, or psychiatry (a term
much affected by our German brethren), would have been more correct and ap¬
propriate ; and that, moreover, we do not deal in mental science, which is pro¬
perly the sphere of the aspiring metaphysical intellect. If mental science is
strictly synonymous with metaphysics, these objections are certainly valid ; for
although we do not eschew metaphysical discussion, the aim of this Journal is
certainly bent upon more attainable objects than the pursuit of those recondite
inquiries which have occupied the most ambitious intellects from the time of
Plato to the present, with so much labour and so little result. But while we
admit that metaphysics may be called one department of mental science, we main¬
tain that mental physiology and mental pathology are also mental science under
a different aspect. While metaphysics may be called speculative mental science,
mental physiology and pathology, with their vast range of inquiry into insanity,
education, crime, and all things which tend to preserve mental health, or to pro¬
duce mental disease, are not less questions of mental science in its practical, that
is in its sociological point of view. If it were not unjust to high mathematics
to compare it in any way with abstruse metaphysics, it would illustrate our
meaning to say that our practical mental science would fairly bear the same rela¬
tion to the mental science of the metaphysicians as applied mathematics bears to
the pure science. In both instances the aim of the pure science is the attainment
of abstract truth; its utility, however, frequently going no further than to serve
as a gymnasium for the intellect. In both instances the mixed science aims at,
and, to a certain extent, attains immediate practical results of the greatest utility
to the welfare of mankind ; we therefore maintain that our Journal is not inaptly
called the Journal of Mental Science, although the science may only attempt to
deal with sociological and medical inquiries, relating either to the preservation of
the health of the mind or to the amelioration or cure of its diseases; and although
not soaring to the height of abstruse metaphysics, we only aim at such meta¬
physical knowledge as may be available to our purposes, as the mechanician uses
the formularies of mathematics. This is our view of the kind of mental science
which physicians engaged in the grave responsibility of caring for the mental
health of their fellow-men may, in all modesty, pretend to cultivate; and while
we cannot doubt that all additions to our certain knowledge in the speculative
department of the science will be great gain, the necessities of duty and of danger
must ever compel us to pursue that knowledge which is to be obtained in the
practical departments of science with the earnestness of real workmen. The cap¬
tain of a ship would be none the worse for being well acquainted with the higher
branches of astronomical science, but it is the practical part of that science as it
is applicable to navigation which he is compelled to study.”— Sir J. C. Bucknill,
M.D., F.R.S.

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PRINCETON UNIVERSITY

-PiO

THE

MEDICO-PSYCHOLOGICAL ASSOCIATION
OF GREAT BRITAIN AND IRELAND.

THE COUNCIL AND OFFICERS. 1919-20.

.r-

■o

EDITORS OF JOURNAL

president.— BEDFORD PIERCE, M.D., F.R.C.P.
president elect. —WILLIAM F. MENZIES, M.D.

EX-president.— JOHN KKAY, C.D.E., M.D., F.R.C.P.
treasurer.— JAMES CHAMBERS, M.A., M.D.

/■JOHN R. LOUD, C.B.E., M.B.

H. DEVINE, O.B.E., M.D, F.R.C.P.

I G. DOUGLAS MoRAE, M.D., F.R.C.P.Edin.
.W. R. DAWSON, C.B.E., M.l) , F.R.C.P.I.
DIVISIONAL secret akv for south-eastern division.

J. NOEL SERGEANT, M.B.
divisional secretary for south-western division.

G. N. BARTLETT, M.B.

divisional secretary FOR NORTHERN and midland division.

T. STEWART ADAIR, M.D.

DIVISIONAL SECRETARY FOR SCOTTISH DIVISION.

ROBT. B. CAMPBELL, M.D., F.R.C.P.

DIVISIONAL SECRETARY FOR IRISH DIVISION.

RICHARD R. LEEPER, F.R.C.S.

GENERAL SECRETARY.

R. WORTH, O.n.E., M.B., B.S.Durh., M.R.C.S., L.R.C.P.Lond.

CHAIRMAN OF PARLIAMENTARY’ COMMITTEE.

H. WOLSELEY-LEWIS, M.D., F.R.C.S.

SECRETARY OF PARLIAMENTARY COMMITTEE.

R. H. COLE, M.D., F.R.C.P.

(both appointed by Parliamentary Committee, and with seats on Council.)

CHAIRMAN OF EDUCATIONAL COMMITTEE.

MAURICE CRAIG, C.U.E., M.D., F.R.C.P., M.P.C.
vice-chairman.— M. A. COLLINS, O.n.E., M.D.

SECRETARY OF EDUCATIONAL COMMITTEE.

A. W. DANIEL. B.A., M.D.

(appointed by Educational Committee, and with seats on Council).
registrar.— ALFRED A. MILLER, M.B.

MEMRBR8 OF COUNCIL.

REPRESENTATIVE.

R. ARMSTRONG-JONES-i

DAVID BOWER
MAURICE CRAIG
A. W. DANIEL
H. T. S. AVELINE
H. C. MACBRYAN
J. W. GEDDES
H. J. MACKENZIE
L. R. OSWALD
J. H. SKEEN

S.E. Dit.

}S.W. Div.
j- N. & M. Div
}Scotland.

REPRESENTATIVE.

M. J. NOLAN
J. MILLS

|Ireland.

NOMINATED.

HELEN BOYLE
K. D. HOTCHKIS
DAVID OUR

G. E. SHUTTLEWORTH
JOHN G. SMITH.
DAVID G. THOMSON.
[The above form the Council.]

EXAMINERS.

fR. II. STEEN, M.D., M.R.C.P.

ENGLAND-! J. G. PORTER-PHILLIPS, M.D., B.S., M.R.C.P.Lond
l M.P.C.

root, and ! de M - ALEXANDER, M.D., C.M.Edin.

SCOTLAND | R U-SWALD; M.l,., C.M.

(M. J. NOLAN, L.R.C.P.&S.I., M.P.C.
Ireland \ F. K. RAINS FORD, M.D., B.A.Dubl.,
( L.R.C.P.&S.E.

L.R.C.P.I.,

Examiners for the Nursing Certificate of the Association :

■Final.—HENRY DEVINE, O.B.E., M.D., B.S., F.R.C.P., M.R.C.S., M.P.C.: N. T.

KERR, M.D., C.M.Edin.; JOHN MILLS, M.B., B.A., R.U.I.
Preliminary .—GEORGE DUNLOP ROBERTSON, L.R.C.S. & l’.Kdin., Dipl. Psych. ;
H. BROUGHAM LEECH, M.D., B Ch.Dublin ; PATRICK O’DOHERTY,

B A., M.B., B Ch., R.U.I.

AUDITORS.

F. H. EDWARDS, M.D., M.R.C.P. G. F. BARnAM, M.A., M.D.Camb.

■W

— ^

185252

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PRINCETON UNIVERSITY

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PARLIAMENTARY COMMITTEE

FLETCHER BEACH.

J. SHAW BOLTON.

A. HELEN BOYLE.

B. H. COLE.

M. A. COLLINS.
MAURICE CRAIG.

R. EAGER.

JOHN KEAY (ex officio).
R. L. LANGDON-DOWN
R. R. LEEPER.

J. R. LORD.

W. F. MENZIES.

A. MILLER.

W. F. NEL18.
BEDFORD PIERCE.

NATHAN RAW.

G. M. ROBERTSON.

J. NOEL SERGEANT.

G. E. SHUTTLEWORTH.
R. PERCY SMITH.

J. G. SOUTAR.

J. BEVERIDGE 8PENCE.
R. H. STEEN.

ROTHSAY C. STEWART.
F. R. P. TAYLOR.

DAVID G. THOMSON.
ERNEST W. WHITE.

J. R. WUITWELL.

H. WOLSELEY-LEWIS.

EDUCATIONAL COMMITTEE.

FLETCHER BEACH.

1. R. H. COLE.

M. A. COLLINS
T. P. CO WEN.

2. MAURICE CRAIG.

A. W. DANIEL.

R. EAGER.

3. B. HART.

4. JOHN KEAY.

W. F. MENZIES.

LIBRARY

FLETCHER BEACH.

HELEN BOYLE.

M. A. COLLINS.

HENRY DEVINE.

BERNARD HART.

THEO. B. HYSLOP.

W. F. NELIS.

BEDFORD PIERCE.

5. GEORGE M. ROBERTSON.

R. PERCY SMITH.

J. G. SOUTAR.

J. BEVERIDGE SPENCE.

6. ROBERT H. STEEN.
FREDERICK R. P. TAYLOR.
DAVID G. THOMSON.

J. R. WHIT WELL.

COMMITTEE.

JOHN KEAY (ex officio).

E. MAPOTHER.

HENRY KAYNER (Chairman).
R. H. STEEN (Secretary).

W. 11. B. STODDART.

DAVID G. THOMSON.

RESEARCH COMMITTEE.

T. STEWART ADAIR.
J. SHAW BOLTON.

J. CHAMBERS.

M. A. COLLINS.

H. DEVINE.

E. GOODALL.

JOHN KEAY.

J. R. LORD.

DAVID ORR.

FORD ROBERTSON.
R. G. ROWS.

R. PERCY SMITH.
R. H. STEEN.

D. G. THOMSON.
W. J. TULLOCH.

Lectures nt:—(I) St. Mary’s Hospital, London; (2) Guy’s Hospital; (3) University
College, London ; (4) Lecturer at School of Medicine, Royal Colleges and Medical
College for Women, Edinburgh; (5) University of Edinburgh and Medical College
for Women, Edinburgh; (6) King’s College Hospital.

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PRINCETON UNIVERSITY

Ill

LIST OF CHAIRMEN.

1811. Dr. Blake, Nottingham.

1842. Dr. de Vitre, Lancaster.

1843. Dr. Conolly, Hanwell.

1844. Dr. Thurnam, York Retreat.

1847. Dr. VVintle, Wameford House, Oxford.

1851. Dr. Conolly, Hanwell.

1852. Dr. Wintle, Wameford House.

LIST OF PRESIDENTS.

1854. A. J. Sutherland, M.D., St. Luke’s Hospital, London.

1866. J. Thurnam, M.D., Wilts County Asylum.

1866. J. Hitchman, M.D., Derby County Asylum.

1857. Forbes Wiuslow, M.D., Sussex House, Hammersmith.

1858. John Conolly, M.D., County Asylum, Hanwell.

1859. Sir Charles Hastings, D.C.L.

1860. J. C. Bucknill, Devon County Asylum.

1861. Joseph Lalor, M.D., Richmond Asylum, Dublin.

1862. John Kirkman, M.D., Suffolk County Asylum.

1863. David Skae, M.D., Royal Edinburgh Asylum.

1864. Henry Munro, M.D., Brook House, Clapton.

1866. Wm. Wood, M.D., Kensington House.

1866. W. A- F. Browne, M.D., Commissioner in Lunacy for Scotland.

1867. C. A. Lockhart Robertson, M.D., Haywards Heath Asylum.

1868. W. H. O. Saukev, M.D., Sandywell Park, Cheltenham.

1869. T. Laycock, M.D., Edinburgh.

1870. Robert Boyd, M.D., County Asylum. Wells.

1871. Henry Maudsley, M.D., The Lawn, Hanwell.

1872. Sir James Coxe, M.D., Commissioner in Lunacy for Scotland.

1873. Harrington Tnke, M.D., Manor House, Chiswick.

1874. T. L. Rogers, M.D., County Asylum, Rainhill.

1875. J. F. Duncan, M.D., Dublin.

1876. W. H. Parsey, M.D., Warwick County Asylum.

1877. 0. Fielding Blaudford, M.D., Loudon.

1878. Sir J. Crichton-Browne, M.D., Lord Chancellor’s Visitor.

1879. J. A. Lush, M.D., Fisherton House, Salisbury.

1880. G. W. Mould, M.R.C.S., Royal Asylum, Cheadle.

1881. D. Hack Tuke, M.D., Loudon.

1882. Sir W. T. Gairdner, M.D., Glasgow.

1883. W. Orange, M.D., State Crimiual Lunatic Asylum, Broadmoor,

1884. Henry Rayner, M.D., County Asylum, Hanwell.

1885. J. A. Eames, M.D., District Asylum, Cork.

1886. Sir Geo. H. Savage, M.D., Bethlem Royal Hospital.

1887. Sir Fred. Needham, M.D., Barnwood House, Gloucester.

1888. Sir T. S. Clouston, M.D., Royal Edinburgh Asylum.

1889. H. Hayes Newington, F.R.C.P., Ticehurst, Sussex.

1890. David Yellow lees, M.D., Gartnavel Asylum, Glasgow.

1891. E. B. Whitcombe, M.R.C.S., City Asylum, Birmingham.

1892. Robert Baker, M.D., The Retreat, York.

1893. J. Murray Lindsay, M.D., County Asylum, Derby.

1894. Conolly Norman, F.R.C.P.I., Richmond Asylum, Dublin.

1895. David Nicolsou, C.B.,M.D., State Criminal Lunatic Asylum, Broadmoor.

1896. William Julius Mickle, M.D., Grove Hall Asylum, Bow.

1897. Thomas W. McDowall, M.D., Morpeth, Northumberland.

1898. A. R. Urquhart, M.D., James Murray’s Royal Asylum, Perth.

1899. J. B. Spence, M.D., Burntwood Asylum, nr. Lichfield, Staffordshire.

1900. Fletcher Beach, M.B., 79, Wimpole Street, W. 1.

1901. Oscar T. Woods, M.D., District Asylum, Cork, Ireland.

1902 J. Wiglesworth, M.D., F.R.C.P., Rainhill Asylum, near Liverpool.

1903. Ernest W. White, O.B.E., M.B.,M.R.C.P.,Betley House, nr. Shrewsbury.

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PRINCETON UNIVERSITY

1904. R. Percy Smith, M.D., F.R.C.P., 36, Queeu Anne Street, Cavendish

Square, London, W. 1.

1905. T. Outterson Wood, M.D., F.R.C.P., 40, Margaret Street, Cavendish

Square, London, W. 1.

1906. Sir Robert Armstroug-Jones, C.B.E., M.D.Lond., B.S., F.R.C.P.,

F.R.C.S.Eng., Clayhury Asylum, Woodford Bridge, Essex.

1907. P. W. MacDonald, M.D., County Asylum, Dorchester.

1908. Chas. A. Mercier, M.D., F.R.C.P., F.R.C.S., 34, Wimpole Street, London,

W. 1.

1909. W. Bevan-Lewis, M.Sc., L.R.C.P., late Medical Director, We9t Riding

Asylum, Wakefield.

1910. John Mncpherson, M.D., F.R.C.P.Edin., Commissioner in Lunacy, 8,

Darnaway Street, Edinburgh.

1911. Wm. R. Dawson, O.B.E., B.A., M.I)., F.R.C.P.I., D.P.H., Inspector of

Lunatic Asylums, Dublin Castle, Dublin.

1912. J. Greig Soutar, M.B., Barmvood House, Gloucester.

1913. James Chambers, M.D., M.Ch., The Priory, Roehampton, S.W.

1914-18. David G. Thomson, C.B.E., M.D., C.M.Edin., County Asylum, Thorpe,

Norfolk.

1918. John Keay, C.B.E., M.D., C.M., F.R.C.P., Ediuburgh War Hospital,

Bangour.

1919. Bedford Pierce, M.D., F.R.C.P., The Retreat, York.

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Honorary and Corresponding Members.

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HONORARY MEMBERS.

1896. Allbutt, Sir T. Clifford, K.C.B., M.D., D.Sc., LL.l)., F.R.C.P., F.R.S.,
Regius Professor of Physic,Univ. Camb.,St. Itadegund’s, Cambridge.
1881. Benedikt, Prof. M., Wien, ix Marianngattse 1, Vienna.

1918. Bevnn-Lcwis, William, M.Sc.Leeds, M.R.C.S., L.R.C.P.Lond., 22,
Cromwell Road, Hove. (Pbesident, 1909-10.)

1907. Bianchi, Prof. Leonardo, Manicoinio Provinciale di Napoli. Musee N. 3,
Naples, Italy. ( Carr. Mem., 1896.)

1900. Blumer, G. Alder, M.U., L.It.C.P.Edin., Butler llospitnl, Providence,
U.S.A. (Ord. Mem., 1890.)

1900. Bresler, Johannes, M.D., Oberartzt, Liihcn in Schlesien, Germany.
(Corr. Mem. 1896.)

1902. Brush, Edward N., M.D., Sheppard and Enoch Pratt Hospital, Towson,
Maryland, U.S.A.

1917. Colies, John Mayne, LL.l). (Univ. l)ub.), K.C., J.P., Registrar in Lunacy

(Supreme Court of Judicature in Ireland), Lunacy Office, Four
Courts, Dublin.

1909. Collins, Sir William J., D.L., M.D., M.S., B.Sc.Lond., F.R.C.S.Eng.,
Meads End, Eastbourne, Sussex.

1912. Considine, Thomas Ivory, F.R.C.S.I., L.R.C.P.I., Inspector of Lunatic
Asylums, Ireland, Office of Lunatic Asylums, Dublin Castle, Dublin.

1918. Cooke, Sir Edward Marriott, K.B.E., M.D., M.lt.C.S.Eng., Commissioner

in Lunacy, 69, Onslow Square, London, S. W. 7.

1902. Conpland, Sidney, M.D., F.It.C.P.Lond., Commissioner of the Board of
Control, “ Plas Gwyn,” Frognal, Hampstead, London, N.W. 3.

1876. Oricbtou-Browne, Sir J., M.D.Edin., LL.D., D.Sc., F.R.S., Lord
Chancellor’s Visitor, Royal Courts of Justice, Strand, London,
W.C. 2., and 45, Hans Place, London, S.W. 1. (Pbesident, 1878.)
1911. Donkin, Sir Horatio Bryan, M.A., M.D.Oxon., F.It.C.P.Lond. (Medieal
Adviser to Prison Commissioners and Director of Convict Prisons),
28, Hyde Park Street, London, W. 2.

1896. Ferrier, Sir David, M.A., M.D., LL.D., F.R.C.P., F.R.S., 34, Cavendish
Square, London, W. 1.

1872. Fraser, John, M.B., C.M., F.R.C.P.E., Formerly Commissioner in
Lunacy, 54, Great King Street, Edinburgh.

1909. Kraepelin, Dr. Emil, Professor of Psychiatry, The University, Munich.

1910. Macpherson, John, M.D., F.R.C.P.Edin., Commissioner in Lunacy, 8,

Daruaway Street, Edinburgh. (Pbesident, 1910-11.) ( Ordinary
Member from 1886.)

1911. Moeli, Prof. Dr. Karl, Director, Herzberge Asylum, Berlin.

1889. Needham, Sir Frederick, M.D.St. And., M.R.C.P.Edin., M.lt.C.S.Eng.,
Commissioner of the Board of Control, 19, Campden Hill Square,
Kensington, London, W. 8. (Pbesidbnt, 1887.)

1909. Obersteiner, Dr. Heinrich, Professorof Neurology, The University, Vienna.
1881. Peeters, M., M.D., Gheel, Belgium.

1900. Ritti, Ant., 68, Boulevard Exelmans, Paris. (Corr. Mem., 1890.)

1911. Semelaigne, R6n6, M.D.Paris, Secretaire des Stances de la Society'
Medico-Psychologique de Paris, 16, Avenue de Madrid, Neuilly,
Seine, France. ( Corresponding Member from 1893.)

1901. Toulouse, Dr. Edouard, Directeur du Laborntoire da Psychologie experi¬

mental it l’Ecole des Hautes Etudes Paris et Medecin en chef de
l’Asile de Villejuif, Seine, France.

1910. Trevor, Arthur Hill, Esq., B.A.Oxon., of the Inner Temple, Barrister at

Law, Commissioner of the Board of Control, 4, Albemarle Street,
London, W. 1.

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CORRESPONDING MEMBERS.

1911. Boedeker, Prof. Dr. Justus Karl Edmund, Privat Docent and Director,
Fichtenhof Asylum, Schlachtensee, Berlin.

1897. Buschnn, Dr. G., Stettin, Germany.

190-4. Caroleti, Wilfrid, Manicomio de Las Corts, Barcelona, Spain.

1896. Cowan, F. M., M.D., 109, Perponcher Straat, The Hague, Holland.

1911. Falkenberg, Dr. Wilhelm, Sanitatstrat, Direktor dcr Berliner staedtischen
Torenanstalt Buch (Bez. Potsdam).

1907. Ferrari, Giulio Cesare, M.D., Director of the Manicomio Provinciale,
Imola, Bologna, Italy.

1911. Friedlander, Prof. Dr. Adolf Albrecht, Director of the Hohe Mark Klinik,
nr. Frankfort.

1901. Gomm&s, Dr. Marcel, 5, Rue Parrot, Paris XII.

1909. Pilcz, Dr. Alexander, VIII/2 Alserstrasse 43, Wien, Austria.

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Members of the Association.

vii

MEMBERS OF THE ASSOCIATION.

Alphabetical List of Members of the Association on December 31*/, 1918, with
the pear in which they joined.

1900. Abbott, Henry Kingsinill, B.A., M.D.Dub., D.P.H.Irel., Medical Superin¬
tendent, Hants County Asylum, Farebani.

1891. Adair, Thomas Stewart, M.D., C.M.Ediu., F.R.M.S., Medical Superin¬
tendent, Storthes Hall Asylum, Kirkburtou, near Huddersfield.
(Mon. Sec. N. and M. Division since 1908.)

1910. Adam, George Henry, M.R.C.S., L.R.C.P.Lond., Manager and Medical
Superintendent, West Mailing Place, Kent.

1913. Adams, John Barfield, L.It.C.P.&S.Edin., M.P.C., 119, Rcdland Rond,
Bristol.

1868. Adams, Josiah O., M.D.Durb., F.R.C.S.Eng., J.P., 117, Cazenove Road,
Stamford Hill, London, N. 16.

1919. Adey, J. K., M.B., C.M.Melbourne, Receiving House, Royal Park,
Melbourne, Australia.

1886. Agar, S. Hollingsworth, jun., B.A.Cautab., M.R.C.S.Eng., L.S.A., Hurst
House, Heuley-in-Arden.

1899. Alexander, Hugh de Maine, M.D., C.M.Ediu., Medical Superintendent,
Aberdeen City District Asylum, Kingseat, Nowmachar, Aberdeen.
1899. Allmann, Dorah Elizabeth, M.B., B.Ch.R.U.l., Assistant Medical Officer,
District Asylum, Armagh.

1908. Anderson, James Richard Sumner, M.B., Ch.H.Gla*., Senior Assistant

Medical Officer, Cumberland and Westmorland Asylum, Garlands,
Carlisle.

1898. Anderson, John Sewell, M.R.C.S., L.R.C.P.Lond., Senior Assistant
Medical Officer, Hull City Asylum, Willerby, near Hull.

1918. Anderson, William Kirkpatrick, M.B., Ch.B.Glas., Dykebur War Hospital,

Paisley ; 2, Woodside Crescent, Glasgow.

1912. Annandale, James Scott, M.B., Ch.B.Edin., Ayr District Asylum, Ayr.

1919. Anthony, Mark, L.R.C.P.I., L.R.C.S.I., Assistant Medical Officer, Bucks

Countv Asylum, Stone, Aylesbury.

1912. Apthorp, Frederick William, M.R.C.S.Eng., L.R.C.P.Edin., M.P.C.,

Senior Medical Officer, St. George’s Retreat, Ravensworth, Burgess
Hill.

1904. Archdale, Mervyn Alex., M.B., B.S.Durh., Medical Superintendent,

County Mental Hospital, Cambridge.

1905. Archdall, Mervyn Thomas, L.R.C.P.&S.Edin., L.S.A.Lond., Brynn-y-

Nenadd Hall, Llanfairfechan, N. Wales.

1918. Archibald, Alexander John, M.B., Ch.B.Glas., Acting Medical Superin¬
tendent, Argyll and Bute District Asylum, Lochgilphead, Argyllshire.
1918. Archibald, Madeline, L.R.C.P., L.R.C.S., Assistant Medicnl Officer, Argyll
and Bute District Asylum, Lochgilphead.

1882. Armstrong-Jones, Sir Robert, C.B.E., M.D.Lond., B.S., F.R.C.P.,
F.R.C.S.Eng., 105, Harley Street, W. 1 (and Pl&s Dinas, Carnarvon,
North Wales). ( Oen. Secretary from 1897 to 1906.) (Prbsidint,
1906-7 )

1910. Auden, G. A., M.A., M.D., B.C., D.P.H.Cuntab.,F.R.C.P.Lond., F.R.C.P..

F.S.A., Medical Superintendent, Educational Offices, Edmund
Street, Birmingham.

1891. Aveline, Henry T. S., M.D.Durb., M.R.C.S., L.R.C.P.Lond., M.P.C.,
Medical Superintendent, County Asylum, Cotford, near Taunton,
Somerset. (Hon. Sec. for S.W. Division, 1905-11.)

1903. Bailey, William Henry, M.D.Lond., M.R.C.S.Eng., L.S.A., D.P.H.Lond.,
Featherstone Hall, Southall, Middlesex.

1909. Bain, John, M.A., M.B., B.Ch.Glasg. (address uncommunicated).

1913. Bainbridge, Charles Frederick, M.B., Ch.B.Edin., Assistant Medical

Officer, Devon Mental Hospital, Exminster.

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viii Members of the Association.

1906. Baird, Harvey, M.D., Cb.B.Edin., Periteau, Winchelsea, Sussex.

1878. Baker, H. Mortou, M.B., C.M.Edin., 7, Belsize Square, London, N.W. 8.
1888. Baker, Sir John, M.D., C.M.Aberd., Medical Superintendent, State
Asylum, Broadmoor, Berks.

1904. Barliam, Quy Foster, M.A., M.D., B.C.Cantab., M.R.C.S., L.R.C.P.Lond.,
Medical Superintendent, Clay bury Asylum, Woodford Bridge, Essex.
1919. Barkns, Mary Rushton, M.R.C.S., L.R.C.P.Lond., Temporary Assistant
Medical Officer, Betblem Royal Hospital, Lambeth, Loudon, S.E. 1;
and 46, Connaught Street, London, W. 2.

1913. Barkley, James Morgan, M.B., Cb.B.Edin. (Senior Medical Officer,
Bracebridge Asylum, Lincolnshire).

1910. Bartlett, George Norton, M.B., H.S.Lond., M.R.C.S., L.R.C.P.Lond.,
Medical Superintendent, City Asylum, Exeter.

1901. Baskin, J. Lougheed, M.D.Brux., L.R.C.P.&S.Edin., L.R.F.P.&S.Glas.

1902. Baugh, Leonard D. H., M.B., Ch.B.Edin., The Pltasaunce, York.

1874. Beach, Fletcher, M.B., F.R.C.P.Lond.,/or»»*W - y Medical Superintendent,

Darenth Asylum, Dartford ; 5, De Crespigny Park, Denmark Hill,
S.E. 5. (Secretary Parliamentary Committee, 1896-1906. General
Secretaiy, 1889-1896. Pbksident, 1900.)

1892. Beadles,Cecil F., M.R.C.S., L.R.C.P.Lond., Gresham House, Egham Hill,
Egham.

1913. Bedford, Percy William Page, M.B., Ch.B.Edin., County Asylum, Lan¬

caster.

1909. Beeley, Arthur, M.Sc.Leeds, M.D., B.S.Lond., M.R.C.S., L.R.C.P.Lond.,
D.P.H.C'amb. ( Assistant Medical Officer, E. Sussex Educational
Committee), Windybank, King Henry’s Rond, Lewes.

1914. Bennett, James Wodderspo'on, M.R.C.S., L.R.C.P.Lond., County Mental

Hospital, Stafford.

1912. Benson, Henry Porter D’Arcy, M.D., C.M.Edin., M.R.C.P., F.R.C.S.

Edin., Medical Superintendent, Farnhain House, Finelas, Dublin.
1914. Benson, John Robinson, F.R.C.S.Eng., L.R.C.P.Lond., Resident Physi¬
cian and Proprietor, Fiddington House, Market Lavington, Wilts.

1899. Beresford, Edwyn H., M.R.C.S., L.R.C.P.Lond., Medical Superintendent,

Tooting ltec Asylum, Tooting, London, S.W. 17.

1912. Berncastle, Herbert M., M.R.C.S.Eng., L.R.C.P.Lond., Assistant Medical,

Officer, Croydon Mental Hospital, Warlingham, Surrey.

1894. Blacbford, James Vincent, C.B.E., M.D., B.S.Durh.,M.R.C.S.,L.R.C.P.
Lond., M.P.C., City Asylum, Fishponds, Bristol.

1913. Black, Robert Sinclair, M.A.Edin., M.D., C.M.Aberd., D.P.H., M.P.C.,

Medical Supt., Pietermaritzburg Mental Hospital, Natal, South
Africa.

1898. Blair, David, M.A., M.D., C.M.GIasg., County Asylum, Lancaster.

1919. Blake, Stanley, L.R.C.P.&S.I.&L.M., Assistant Medical Officer, Portrane
Asylum, Donabate, Ireland.

1919. Blakistou, Frederick Cairns, M.R.C.S., L.R.C.P., Medical Superintendent,
Isle of Man Asylum.

1897. Blandford, Joseph John Guthrie, B.A., D.P.H.Cnmb., M.R.C.S., L.R.C.P.
Lond., Whallcy Asylum, Blackburn.

1918. Blandford, Walter Folliott, B.A.Cainb., M.R.C.S., L.R.C.P.Lond.,
Temporary Assistant Medical Officer, Caterham Asylum, Caterhnm,
Surrey.

1904. Bodvel-Roberts, Hugh Frank, M.A.Cantab., M.R.C.S., L.R.C.P.Lond.,
L.S.A., Napsbury Mental Hospital, near St. Albans, Herts.

1900. Bolton, Joseph Shaw, M.D., B.S., D.Sc., F.R.C.P.Lond., Medical Super¬

intendent, West Riding Asvlnin, Wakefield.

1892. Bond, Charles Hubert, D.Sc., M'.D., C.M.Edin., F.R.C.P.Lond., M.P.C.,
Commissioner of the Board of Control, 66, Victoria Street, London,
S.W. 1. (Son. General Secretary, 1906-12.)

1918. Bower, Cedric William, L.M.S.S.A., Joint Medical Officer, Springfield
House, near Bedford.

1877. Bower, David, M.D., C.M.Aber.,Springfield House, Bedford. (Chairman,
Parliamentary Committee, 1907-1910.)

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Members of the Association.

1877. Bowes, John Ireland, M.R.C.S.Eng., L.S.A. (address uncommunicated.)

1917. Bowie, Edgar Ormond, L.A.H.Dnb., Dip. Grant Med. Coll. Bombay,

L.M.Coombe, Dublin; e/o \V. H. Halliburton, Esq., 18, South
Frederick Street, Dublin.

1900. Bowles, Alfred, M.R.C.S., L.K.C.P.Lond., 10, South ClilV, Eastbourne.
1896. Boycott, Arthur N., M.D.Lond., M.R.C.S., L.K.C.P.Lond., Medical
Superintendent, Herts Comity Asylum, Hill End, St. Albans, Herts.
{Hon. Sec. for S.-E. Division, 1900-05.)

1898. Boyle, A. Helen A., M.D.Brux., L.R.C.P.&S.Edin., 9, The Drive, Hove,
Brighton.

1883. Boys, A. H., L.R.C.P.Ediu., M.R.C.S.Eng., L.S.A.Lond., The White
House, St. Albuus.

1891. Brainc-Hartuell, George M. 1\, M.R.C.S., L.R.C.P.Loud., Medical
Superintendent, County and City Asylum, Powick, Worcester.

1911. Brander, John, M.B., C.B.Edin., Assistant Medical Officer, London

County Mental Hospital, Bexlev, Kent.

1919. Brauthwaite, Robert Welsh, C.B., M.D.Brux., M.R.C.S., L.R.C.P.,
D.P.H.Lond., Commissioner of the Board of Control, 66, Victoria
Street, London, S.W. 1.

1918. Brend, William Alfred, M.D.Lond., 14, Bolingbroke Grove, London,

S.W. 11.

1905. Brown, Harry Egcrton, M.D., Ch.B.Glasg., M.P.C., Mental Hospital,
Fort Beaufort, Cape Province, S. Africa.

1908. Brown, Robert Cunyngham, O.B.E.. M.D., B.S.Durh. (General Board of
Lunacy, 25. Palmerston Place, Edinburgh); Administrator, Spring-
burn and Woodside Central Hospital, Glasgow.

1908. Brown, R. Dods, M.D., Ch.B., F.R.C.P., Dipl. Psych., D.P.H.Edin.,
Medical Superintendent, The Royal Asylum, Aberdeen.

1912. Brown, William, M.D., C.M.Glas., M.P.C., District Medical Officer,

Adviser in Lunacy to Bristol Magistrates, 1, Manor Road, Fish¬
ponds, Bristol.

1916. Brown, William, M.A., M.B., B.Ch.Oxon., D.Sc.Lond., Reader in

Psychology in the University of London (King’s College), (King’s
College, Strand, London, W.C. 2); 14, Welbeck Street, W. 1.

1917. Bruce, Alexander Nininu, M.D., D.Sc., F.R.C.P.E., Lecturer on Neuro¬

logy, University of Edinburgh, 8, Ainslie Place, Edinburgh.

1893. Bruce, Lewis C., M.C., M.D., F.R.C.P.Ediu., M.P.C., Medical Superinten¬

dent, District Asylum, Druid Park, Murthly, N.B.) ( Co-Editor of
Journal 1911-1916; Hon. Sec. for Scottish Division, 1901-1907.)

1913. Bruuton, George Llewellyn, M.D., Ch.B.Edin., North Riding Asylum,

Clifton, York.

1912. Buchanan, William Murdoch, M.B., Ch.B.Gins., Kirklands Asylum,
Bothweli, Lanarkshire.

1908. Bullmore, Charles Cecil, J.P., L.R.C.P.&S.Ediu., L.R.F.P.&S.Glas.,

Medical Superintendent, Flower House, Catford, London, S.E. 6.

1912. Burke, J. I)., M.B., B.Ch., R.U.I,, St. Audry’s Hospital, Melton, Suffolk.
1911. Buss, Howard Decimus, B.A., B.Sc. France, M.D.Brux.&Cape, M.R.C.S.,

L.R.C.P., L.M.S.S.A.Lond., Assistant Medical Officer, Fort
Beaufort Asylum, Cape Colony.

1910. Cahir, John P., M.B., B.Ch.R.U.I., 198, Camberwell New Road, Camber¬
well, London, S.E. 5.

1891. Caldecott, Charles, M.B., B.S.Lond., M.R.C.S., L.R.C.P.Lond., Medical
Superintendent, Royal Earlswood Institution, Redhill, Surrey.

1913. Cameron, John Allan Munro, M.B., Ch.B.Glas. Address uucommuni-

cated.

1894. Campbell, Alfred Walter, M.D., C.M.Ediu., M.P.C., Macquarie Chambers,

183, Macquarie Street, Sydney, New South Wales.

1909. Campbell, Donald Graham, M.B., C.M.Edin., “ Auchinellan,” 12, Reid-

haven Street, Elgin.

1914. Campbell, Finlay Stewart, M.D., C.M.Glas., Deputy Director of Medical

Services, Ministry of National Service, Ayr, Scotland.

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x Members of the Association.

1897. Campbell, Robert Brown, M.D., C.M., F.R.C.P.E., Stirling District
Asylum, Larbert. ( Secretary for Scottish Division from 1910.)

1905. Carre, Henry, L.R.C.P.&S. Irel., Woodilee Asylum, Lenzie, Glasgow.

1891. Carswell, John, L.R.C.P.Edin., L.R.F.P.&S.Gluser., 43, Moray Place,

Edinburgh ; Commissioner-General, Board of Control, Scotland.
1874. Cassidy, D. M., M.D., C.M.McGill Coll., Montreal, D.Sc. (Public
Health) F.R.C.S.Edin., Medical Superintendent, County Asylum,
Lancaster.

1888. Chambers, James, M.A., M.D.R.U.I., M.P.C., The Priory, Roehampton,
London, S.W. 15. ( Co-Editor of Journal 1905-1914, Assistant
Editor 1900-05.) (Pbksidbnt, 1913-14.) ( Treasurer since

1917.)

1911. Chambers, Walter Dunenuon, M.A., M.D., Ch.B.Edin., M.P.C., Deputy
Commissioner, 1, Craiglen Place, Edinburgh.

1865. Chapman, Thomas Algernon, M.D.Glas., L.R.C.S.Edin., F.R.S., F.Z.S.,
Betula, Reigate.

1915. Cheyne, Alfred William Harper, M.B., Ch.B.Aber., Assistant Medical
Officer, Royal Asylum, Aberdeen.'

1917. Chisholm, Percy, L.R.C.P. A S.Edin., Assistant Medical Officer, Stirling
District Asylum, Larbert.

1907. Chislett, Charles G. A., M.B., Ch.B.Glasg., Medical Superintendent,
Stoneyetts, Chryston, Lanark.

1880. Christie, J. W. Stirling, L.R.C.P.&S.Edin., 21, St. Matthew’s Gardens,
St. Leonards-on-Sea.

1878. Clapham, Win. Crochley S., M.D., F.R.C.P.Ed., M.R.C.S.Eng., F.S.S., The
Five Gables, May field, Sussex. {Ron. See. N. and M. Division,
1897-1901.)

1907. Clarke, Geoffrey, M.D.Lond., Senior Assistant Medical Officer, London
County Mental Hospital, Banstead, Sutton, Surrey.

1910. Clarke, James Kiliau P., M.B., B.Ch.R.U.I., D.P.H., High Street,
Oakham.

1907. Clarkson, Robert Durward, B.Se., M.D., C.M.Edin., F.R.C.P.Edin.

(Medical Officer, Scottish National Institute for the Education of
Imbecile Children), The Park, Larbert, Stirling.

1892. Cole, Robert Henry, M.D.Lond., F.R.C.P.Lond.. 25, Upper Berkeley

Street, London, W. 1. ( Secretary of Parliamentary Committee

since 1912.)

1900. Cole, Sydney John, M.A., M.D., B.Ch.Oxon., Medical Superintendent,
Wilts County Asylum, Devizes.

1906. Collier, Walter Edgar, M.R.C.S., L.R.C.P.Lond., Assistant Medical

Officer, Kent County Asylum, Maidstone.

1903. Collins, Michael Abdy, O.B.E., M.l)., B.S.Loud..M.R.C.S.,L.R.C.P.Lond.,
Chartlmm Down, near Canterbury, Kent. {Ron. General Secretary,
1912-18.)

1910. Conlon, Thomas Peter, L.R.C.P.&S.Irel., Resident Medical Superin¬
tendent, District Asylum, Monaghan.

1914. Connolly, Victor Lindley, M.C., M.B., B.Cli.Belfast, Assistant Medical
Officer, Long Grove Mental Hospital, Epsom, Surrey.

1910. Coombes, Percival Charles, M.R.C.S., L.R.C.P.Lond., Medical Superin¬
tendent, Surrey Countv Asylum, Netherne.

1905. Cooper, K. D., L.R.C.P.&S.Edin., L.R.F.P.&S.Glas., c/o Leopold & Co.
Apollo, Bunder, Bombay.

1903. Cormac, Harry Dove, M.B., B.S.Madras, Medical Superintendent,
Cheshire County Asylum, Macclesfield.

1891. Corner, Harry, M.D.Lond.,M.R.C.S., L.R.C.P.Lond., M.P.C.,37, Harley
Street, London, W. 1.

1917. Costello, Christopher, M.B., B.Cli., N.U.I., Assistant Medical Officer,
Portrane Asylum, Ireland.

1897. Cotton, William, M.A., M.l).Edin., D.P.H.Cantab., M.P.C.,231,Gloucester
Road, Bishopston, Bristol.

1910. Coupland, William Henry, L.R.C.S.&P.Edin., Medical Superintendent,.

Royal Albert Institution, Albert House, Haverbreaks, Lancaster.

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1913. Court, E. Percy, M.R.C.S., L.R.C.P.Lond., Severalls Asylum, Colchester.
1893. Cowen, Thomas Philip, M.D., B.S. M.R.C.S., L.R.C.P.Lond., Medical

Superintendent, County Asylum, Rainhill, Lancashire.

1911. Cox, Donald Maxwell, M.R.C.S., L.R.C.P.Lond., 2, Royal Park, Clifton,
Bristol.

1918. Cox, Francis Michael, M.D., F.R.C.P.Lond., Physician, St. Vincent’s

Hospital, Dublin; Lord Chancellor’s Consulting Visitor in Lunncy
for County and City of Dublin; 20, Merrion Square, Dublin.

1893. Craig, Maurice, C.B.E., M.A., M.D.,B.C.Cautab., F.R.C.P.Lond., M.P.C.,

87, Harley Street, London, W. 1. (Hon. Secretary o f Educational
Committee, 1905-8; Chairman of Educational Committee since
1912.)

1897. Cribb, Harry Gifford, M.R.C.S., L.R.C.P.Lond., Medical Superintendent,
Winterton Asylum, Ferryhill, Durham.

1911. Crichlow, Charles Adolphus, M.B., Ch.B.Glas. Roxburgh District
Asylum, Melrose.

1917. Crocket, James, M.D.Ediu., D.P.H., Medical Superintendent, Colony of
Mercy for Epileptics, Consumption Sanatoria of Scotland, Craigielea,
Bridge of Weir.

1914. Crookshauk, Francis Graham, M.D., M.R.C.P.Loud., 15, Harley Street,

London, W. 1.

1904. Cross, Harold Robert, L.S.A.Loud., F.R.G.S., Storthes Hall Asylum,

Kirkburtou, near Huddersfield.

1915. Crosthwaite, Frederick Douglas, M.B., Ch.B.Edin., D.P.H,Cantab.,

Assistant Physician, Pretoria Mental Hospital, South Africa.

1914. Cruicksliank, J., M.D., Ch.B.Glas., Pathologist, Crichton Royal Hospital,
Dumfries.

1919. Cuthbert, James Harvey, M.B., Ch.B.Edin., Senior Assistant Medical

Officer, West Ham Mental Hospital, Goodmayes, Essex.

1907. Daniel, Alfred Wilson, B.A., M.D., B.C.Cantab., M.R.C.S., L.R.C.P.Lond.,

Medical Superintendent, London County Mental Hospital, Hanwell,
London, W. 7. • (Secretary of Educational Committee.)

1896. Davidson, Andrew, M.D., C.M.Aber., M.P.C., Wyoming, Macquarie
Street, Sydney, N.S.W.

1914. Davies, Laura Katherine, M.B., Ch.B.Edin., Pathologist and Assistant

Medical Officer, Edinburgh City Asylum, Bangour, Dechmont,
Linlithgowshire.

1891. Davis, Arthur N., L.R.C.P.&S.Edin., Medical Superintendent, County
Asylum, Exminster, Devon.

1894. Dawson, William R., O.B.E., B.A.,M.D.,B.Ch.Dubl., F.R.C.P.I..D.P.H.,

Inspector of Lunatics in Ireland, 7, Ailesbury Road, Dublin. (Hon.
Sec. to Irish Division, 1902-11; President, 1911-12; Co-Editor
of the Journal since 1920.)

1901. De Steiger, Addle, M.D.Lond., County Asylum, Brentwood, Essex.

1905. Devine, Henry, O.B.E., M.D., B.S., F.R.C.P.Lond., M.R.C.S.Eng.,

M.P.C., Medical Superintendent, The Asylum, Milton, Portsmouth.
(Co-Editor of the Journal since 1920; Assistant Editor 1916-20.)

1904. Devon, James, L.R.C.P. & S.Edin., 11, Rutland Square, Edinburgh.

1903. Dickson, Thomas Graeme, L.R.C.P. & S.Edin., The Mcrse Cottage,

Bakewell, Derbyshire.

1915. Dillon, Frederick, M.B., Ch.B.Edin., Assistant Medical Officer,

Northumberland House, Green Lanes, Finsbury Park, London, N. 4.
1909. Dillon, Kathleen, L.R.C.P.&S.I., Assistant Medical Officer, District
Asylum, Mullingar.

1905. Dixon, J. Francis, M.A., M.D., B.Ch.Dubl., M.P.C., Medical Super¬

intendent, Borough Mental Hospital, Humberstone, Leicester.

1879. Dodds, William J., M.D., C.M., D.Sc.Edin., 15, Marina Road, Prestwick,
Ayrshire.

1908. Donald, Robert, M.D., Ch.B.Glas., 3, Gilmour Street, Paisley.

1889. Donaldson, William Ireland, B.A., M.D., B.Ch.Dubl., 2, Abbeylands,
Killiney, Co. Dublin.

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Digitized by

xii Members of the Association.

1892. Donelau, John O’Conor, L.R.C.P.&S.I., M.P.C., St. Dymphna’s, North
Circular Hoad, Dublin (Med. Supt., Richmond Asylum,
Dublin).

1890. Douglas, William, M.D.R.U.I., M.R.C.S.Eng., F.R.O.S., Brandfold,

Goudhurst, Kent.

1905. Dove, Augustus Charles, M.D., B.S.Durh., M.R.C.S.Eng., “ Briglitside,”

Crouch End Hill, London, N. 2.

1910. Downey, Michael Henry, M.B., Ch.B.Melb., L.R.C.P. & S.Edin.,

L.R.F.P. & S. Glasg., Medical Superintendent, Parkside Asylum,
Adelaide, South Australia.

1919. Drake-Brockman, Henry George, M.R.C.S., L.R.C.P.Lond., The Mental
Hospital, Middlesbrough.

1916. Drummond, William Blackley, M.B., C.M.Edin., F.lt.C.P.Edin., Medical

Superintendent, Baldovan Institution, Dundee.

1907. Dryden, A. Mitchell, M.B., Ch.B.Edin., Senior A.M.O., Woodilee Mental
Hospital, Lenzie.

1902. Dudgeon, Herbert Win., M.D., B.S.Durh., M.ll.C.S., L.R.C.P.Lond.,

Medical Superintendent, Khanka Government Asylum, Egypt.
1899. Dudley, Francis, L.R.C.P.&S.I., Senior Assistant Medical Officer,
County Asylum, Bodmin, Cornwall.

1915. Duff, Thomas, L.R.C.P. & S.Edin., L.R.F.P.&S.Glasg., Collington Rise,
Bexhill-on-Sea.

1917. Dunn, Edwin Lindsay, M.B., B.Ch.Dub., Medical Superintendent, Berks

County Asylum, Wallingford, Berks.

1903. Dunston, John Thomas, M.D., B.S.Lond., Medical Superintendent, West

Koppies Mental Hospital, Pretoria, South Africa.

1911. Dykes, Percy Armstrong, M.R.C.S., L.R.C.P.Lond., c/o Messrs. Holt

and Co., 3, Whitehall Place, London, S.W. 1.

1899. Fades, Albert I., L.R.C.P. & S. I. .Medical Superintendent, North Riding
Asylum, Clifton, Yorks.

1906. Eager, Richard, O.B.E., M.D., Ch.B.Aber., M.P.C., Assistant Medical

Officer, The Devon Mental Hospital, Exminster.

1891. Earls, James Henry, M.D., M.Ch.R.U.I., D.P.H., L.S.A.Lond., M.P.C.,

Barrister-at-Law, Fenstanton, Christchurch Road, Streatham Hill,
London, S.W. 2.

1907. East, Win. Norwood, M.D.Lond., M.R.C.S., L.R.C.P.Lond., M.P.C.,

H.M. Prison, Manchester; 17, Walton Park, Liverpool.

1895. Ensterhrook, Charles C., M.A..M.D., F.R.C.P.Ed., M.P.C., J.P., Physician
Superintendent, Crichton Royal Institution, Dumfries.

1914. Eder, M. D„ B.Sc.Loud., M.R.C.S., L.R.C.P.Lond. (Medical Officer,
Deptford School Clinic), 37, Welbeck Street., London, W. 1.

1895. Edgerley, Samuel, M.A., M.D., C.M.Edin., M.P.C., Medical Superinten¬
dent, West Riding Asylum, Menston, nr. Leeds.

1897. Edwards, Francis Henry, M.D.Brux., M.R.C.P.Lond., M.R.C.S.Eng.,

Medical Superintendent, Camberwell House, London, S.E.5.

1919. Eggleston, Henry, M.B., B.S.Durh., Allerton Tower Home of Recovery,
Woolton, Liverpool.

1901. Elgee, Samuel Charles, O.B.E., L.R.C.P.&S.I., Medical Superintendent,
Cane Hill Mental Hospital, Conlsdon, Surrey.

1898. Elkins, Frank Ashby, M.D., C.M.Edin., M.P.C., Medical Superintendent,

Metropolitan Asylum, Leavesden, Herts.

1912. Ellerton, John Frederick Heisc, M.D.Brux., M.R.C.S.Eng., L.R.C.P.

Edin., Rotherwood, Leamington Spa.

1917. Ellis, Vincent C., M.B., B.Ch.Dub., Assistant Medical Officer, Richmond
Asylum, Grangegorman, Dublin.

1908. Ellison, Arthur, M.ll.C.S., L.R.C.P.Eng., Deputy Medical Officer, H.M.

Prison, Leeds; 10, Sholebroke Avenue, Leeds.

1899. Ellison, F. C., B.A., M.D., B.Ch.Dub., Resident Medical Superintendent,

District Asylum, Castlebar.

1911. Emslie, Isabella Galloway, M.I)., Ch.B.Edin., West House, Royal Asylum,
Morningside, Edinburgh.

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Members of the Association. xiii

1911. English, Adn, M.B., B.Ch.R.U.I., Assistant Medical Officer, District
Asylum, Ballinasloe.

1901. Erskine, Wm. J. A., M.D., C.M.Edin., Medical Superintendent, County

Asylum, Whitecroft, Newport, I. of W.

1895. Enrich, Frederick Wilhelm, M.D., C.M.Edin., 8, Moruiugton Villas,
Maningbani Lane, Bradford.

1894. Eustace, Henry Marcus, B.A., M.D., B.Ch.Dubl., M.P.C., Medical
Superintendent, llnmpstead and Highfield Private Asylum,
Glasneviu, Dublin.

1909. Eustace, William Neilson, L.R.C.S. & P.Trel., Lisrouagb, Qlasnevin,
Co. Dublin.

1918. Evans, A. Edward, M.B., B.S.Lond., M.R.C.S., L.R.C.P.Loud., D.P.H.

Liverp , Inspector, Board of Control, 3, Rothcrwick Court, Oolders
Green, London, N.W. 4.

1909. Evans, George, M.B.Lond., Senior Assistant Medical Officer, Severalls
Asylum, Colchester.

1918. Evans, Tudor Benson, M.B., Ch.B.Liverp., 247, Boundary Street, Liver¬
pool.

1891. Ewan, John Alfred, M.A. St. And., M.D., C.M.Edin., M.P.C., Groylees,
Sleaford, Lines.

1914. Ewing, Cecil Wilmot, L.R.C.P. & S.I. (Second Assistant Medical Officer,
Cbarlham Asylum, near Canterbury), Lord Derby War Hospital,
Warrington.

1907. Exley, John, L.R.C.P.I., M.R.C.S.Eng., Medical Officer, II.M. Prison;
Grove House, New Wortley, Leeds.

1894. Farquliarson, William F., M.D., C.M.Edin., M.P.C., Medical Superin¬
tendent, Comities Asylum, Garlands, Carlisle.

1907. Farrics, John Stothart, L.R.C.P.AS.Edin., L.R.F.P.&S.Glas., The Cottage,

Hetbersgill, Carlisle.

1903. Fennell, Charles Henry, M.A., M.D.Oxou, M.R.C.P.Lond., Reform Club,
Pall Mull, London, S.W. 1.

1908. Fenton, Henry Felix, M.B., Ch.B.Edin., Assistant Medical Officer,

County and City Asylum, Powick, Worcester.

1907. Farguson, J. J. Harrower, M.B., Ch.B.Edin., Seuior Assistant Medical

Officer, Fife and Kinross Asylum, Cupar, Fife.

1906. Fielding, Saville James, M.B., B.S.Durb., Medical Superintendent,
Bethel Hospital, Norwich.

1873. Finch, John E. M., M.A., M.D.Cantab., M.R.C.S.Eng., L.S.A.Lond.,
Holmdale, Stoneygate, Leicester.

1889, F'inlay, David, M.D., C.M.Glasg., Medical Superintendent, County
Asylum, Bridgend, Glamorgan.

1906. Firth, Arthur Harcus, M.A., M.D., B.Ch.Edin., Deputy Medical Super¬
intendent, Barnsley Hall, Brotnsgrove, Worcestershire.

1903. Fitzgerald, Alexis, L.R.C.P. & S.I., Medical Superintendent, District

Asylum, Waterford.

1888. Fitz Gerald, Gerald C., B.A., M.D., B.C.Cantnb., M.P.C., 7, Mermaid
Street, Rye, Sussex.

1908. Fitzgerald, James Francis, L.R.C.P.&S.Irel., Assistant Medical Officer,

District Asylum, Clonmel, co. Tipperary, Ireland.

1904. Fleming, Wilfrid Louis Remi, M.R.C.S., L.R.C.P.Lond., Suffolk House,

Pirbright, Surrey.

1894. Fleury, Eleonora Lilian, M.D., B.Ch.R.U.I., Assistant Medical Officer,
Richmond Asylum, Dublin.

1908. Flynn, Thos. Aloysins, L.R.C.P.AS.I., County Asylum, Thorpe, Norwich.

1902. F'orde, Michael J., M.D., B.Ch.R.U.I., Assistant Medical Officer, Rich¬

mond Asylum, Dublin.

1911. Forrester, Archibald Thomas William, M.D., B.S., M.R.C.S., L.R.C.P.

Lond., Senior Assistant Medical Officer, Leicester and Rutland
Counties Asylum, Narhorough.

1916. Forsyth, Charles Wesley, M.B., M.R.C.S., L.R.C.P.Lond., Assistant
Medical Officer, Kesteven County Asylum, Sleaford, Lines.

Original from ^

PRINCETON UNIVERSITY

Digitized by

xiv Members of the Association.

1913. Forward, Ernest Lionel, M.R.C.S., L.R.C.P.Lond., Wharncliffe War
Hospital, Sheffield.

1913. Fothergill, Claude Francis, B.A., M.B., B.C.Cantab., M.R.C.S., L.R.C.P.
Lond.; Hensol, Chorley Wood, Herts.

1912. Fox, Charles J., M.R.C.S., L.R.C.P.Lond., The Moat House, Alnechurch,
Birmingham.

1881. Fraser, Donald, M.D., C.M.Glasg., F.R.F.P. & S.Glas., 13, Royal Terrace
West, Glasgow.

1919. Fraser, Kate, B.Sc., M.D., D.P.H., Deputy Commissioner, General Board
of Control, Scotland; 13, Royal Terrace West, Glasgow.

1901. French, Louis Alexander, M.R.C.S., L.R.C.P.Lond., “Locksley,”

Willingdon, Eastbourne.

1902. Fuller, Lawrence Otway, M.R.C.S.Eng., L.R.C.P.Lond., Medical Super¬

intendent, Three Counties’ Asylum, Arlesey, Beds.

1914. Gage, John Munro, L.R.C.P.&S.I., M.P.C., Royal Earlswood Institution,
Redhill, Surrey.

1906. Gane, Edward Palmer Steward, M.D.Durh., M.R.C.S., L.R.C.P.Lond.,
The Coppice, Nottingham.

1912. Garry, John William, M.B., B.Ch., N.U.I., Assistant Medical Officer,
Ennis District Asylum, Ireland.

1912. Gavin, Lawrence, M.B., Cb.B.Edin,, L.R.C.P.&S.Edin., L.R.F.P.AS.
Glasg., Superintendent, Mullingar District Asylum, Ireland.

1896. Geddes, John W., M.B., C.M.Edio., Medical Superintendent, Mental

Hospital, Middlesbrough, Yorks.

1892. Gemmel, James Francis, M.B.Glasg., Medical Superintendent, County
Asylum, Whittingham, Preston.

1919. Gifford, John, B.A., M.B., Ch.B., Senior Assistant Medical Officer,
Derby County Asylum, Mickleover.

1899. Gilflllan, Samuel James, M.A., M.B., C.M.Edin., Medical Superintendent,
London County Mental Hospital, Colney Hatch, Loudon, N. 11.
1912. Gill, Eustace Stanley Hayes, M.B., Ch.B.Liverp., Shaftesbury House,
Formby, Liverpool.

1889. Gill, Stanley A., B.A.Dubl., M.D.Durh., M.R.C.P.Lond., M.R.C.S.Eng.,
Shaftesbury House, Formby, Liverpool.

1904. Gillespie, Daniel, M.C., M.D., B.Ch.R.U.I., Dipl. Psych., Wadsley Asylum,
near Sheffield.

1897. Gilmour, John Rutherford, M.B., C.M., F.R.C.P.Edin., M.P.C., Medical

Superintendent, West Riding Asylum, Scalebor Park, Burley-in-
Wharfedale, Yorks.

1906. Gilmour, Richard Withers, M.B., B.S.Durh., M.R.C.S., L.R.C.P.Lond.,
Homewood House, West Meon, Hants.

1878. Glcndinning, James, M.D.Glasg., L.R.C.S.Ediu. Hill Crest, Lansdown
Road, Abergavenny.

1897. Good, Thomas Saxty, M.R.C.S.Eng., L.R.C.P.Lond., Medical Superin¬
tendent, County Asylum, Littlemore, Oxford.

1889. Goodall, Edwin, C.B.E., M.D., B.S., F.R.C.P.Loud., M.P.C., Medical
Superintendent, City Mental Hospital, Cardiff.

1918. Goodfellow, Thomas Ashton, M.D.Loud., B.Sc., M.R.C.S., L.R.C.P.,
60, Palatine Road, West Didsbury, Manchester.

1899. Gordon, James Leslie, M.D., C.M.Aberd. (Medical Superintendent,
Fountain Temporary Asylum, Tooting Grove, Tooting Graveney,
London, S.W. 17).

1906. Gordon-Munn, John Gordon, M.D.Edin., F.R.S.E., Heigham Hall,
Norwich.

1901. Gostwyck, C. H. G., M.B., Ch.B., F.R.C.P.Edin., M.P.C., Dipl. Psych.,
Stirling District Asylum, Larbert,

1912. Graham, Gilbert Malise, M.B., Cb.B.Edin., R.N., H.M.S. “Emperor of
India.”

1914. Graham, Norman Bell, M.C., B.A., R.U.I., M.B., B.Ch.Belfast, Assistant
Medical Officer, District Asylum, Belfast.

Google

Original from

PRINCETON UNIVERSITY

Members of the Association.

1894. Graham, Samuel, L.R.C.P.Lond., Resident Medical Superintendent,
District Asylum, Antrim.

1918. Graham, Samuel John, L.R.C.P., L.li.C.S.Edin., L.R.F.P.S.Glasg.,
Resident Medical Superintendent, Villa Colony Asylum, Purdys-
burn, Belfast.

1908. Graham, William S., M.B., B.Ch.R.U.I., Assistant Medical Officer,

Somerset and Bath Asylum, near Taunton.

1915. Graves, T. Chivers, M.B., B.S., B.Sc.Loud., F.lt.C.S.Eng., Medical Super¬

intendent, The Asylum, Rubery Hill, nr. Birmingham.

1916. Gray, Cyril, L.R.C.P.&.S.Edin., Gateshead Borough Asylum, Stanningtou,

Newcastle-on-Tyne.

1909. Greene, Thomas Adrian, L.R.C.S.&P.Irel., J.P., Medical Superintendent,

District Asylum, Carlow.

1886. Greenlees, T. Duncan, M.D., C.M.Edin., F.R.S.E., Rostrevor, Kirtleton
Avenue, Weymouth.

1912. Greeson, Clarence Edward, M.D., Ch.B.Aberd., c/o Messrs. Holt & Co.,
3, Whitehall Place. London, S.W. 1.

1915. Grigsby, Hamilton Marie, L.R.C.P.&S.Edin., 79, Victoria Road North,

Southsea.

1901. Grills, Galbraith Hamilton, M.D., B.Ch.R.U.I., Dipl. Psych., Medical
Superintendent, County Asylum, Chester.

1916. Grimbly, Alan F., B.A., M.A., M.D.Triu.Coll.Dublin, B.Ch., B.A.O.,

L.M.Rot.Dub. (Assistant Medical Officer, St. Edmoudsbury, Lucan,
Ireland); R.N. Hospital, Chatham.

1900. Grove, Ernest George, M.R.C.S., L.R.C.P.Lond., Bootham Park, York.
1894. Gwynn, Charles Heury, M.D., C.M.Edin., M.li.C.S.Kng., co-Licensee,
St. Mary’s House, Whitchurch, Salop.

1894. Halsted, Harold Cecil, M.D.Durh., M.R.C.S., L.R.C.P.Lond., Manor
Road, Selsey, Sussex.

1901. Harding, William, C.B.E., M.D.Edin., M.R.C.P.Lond., Medical Superin¬
tendent, Northampton County Asylum, Berry Wood, Northampton.

1899. Harmcr, W. A., L.S.A., Resident Superintendent and Licensee, Redlands

Private Asylum, Tonbridge, Kent.

1904. Harper-Smith, George Hastie, B.A.Cantab., M.R.C.S., L.R.C.P.Lond.,

(Senior Assistant Medical Officer, Brighton County Borough
Asylum, Haywards Heath), May Cottage, Loughton, Essex.

1898. Harris-Liston,L.,M.l).Brux.,M.R.C.S.,L.R.C.P.Lond., L.S.A., Middleton
Hall, Middleton St. George, Co. Durham.

1905. Hart, Bernard, M.D.Lond., M.R.C.S.Eng., 81, Wimpole Street, London,

W. 1, aud Northumberland House, Finsbury Park, London, N. 4.
1886. Harvey, Bagenal Crosbie, L.lt.C.P.&S.Edin., L.A.H.Dubl., Resident
Medical Superintendent, District Asylum, Clonmel, Ireland.

1892. Haslett, William John H., M.R.C.S., L.R.C.P.Lond., M.P.C., Resident
Medical Superintendent, Halliford House, Sunbury-on-Thames.
1891. Havelock, John G., M.D., C.M.Edin., Cluny, Swanage, Dorset.

1890. Hay, J. F. S., M.B., C.M.Aberd., Inspector-General of Asylums for New
Zealand, Government Buildings, Wellington, New Zealand.

1900. Haynes, Horace E., M.R.C.S.Eng., L.S.A., J.P., Littleton Hall, Brent¬

wood, Essex.

1911. Heffernan, P., B.A., M.B., B.Ch.C.U.I.

1916. Henderson, David Kennedy, M.D.Edin., Senior Assistant Physician,
Royal Asylum, Gartnavel, Glasgow.

1905. Henderson, George, M.A., M.B., Ch.B.Edin., 25, Commercial Road,
Peckham, London, S.E. 15.

1877. Hetherington, Charles E., B.A., M.B., M.Ch.Dubl., Medical Superin¬
tendent, District Asylum, Londonderry, Ireland.

1877. Hewson, R. W., L.R.C.P.&S.Edin., Medical Superintendent, Coton Hill,
Stafford.

1914. Hewson, R. W. Dale, L.R.C.P.&S.Edin., L.R.F.P.&S.Glas., Coton Hill
Hospital, Stafford.

Digitized by Google

Original from

PRINCETON UNIVERSITY

XVI

Members of the Association.

Digitized by

1912. Higson, William Davis, M.B., Ch.B.Liverp., D.P.H., Deputy Medical
Officer, H.M. Prison, Brixton; 7, Clovelly Gardens, Upper Tulse
Hill, London, S.W. 2.

1882. Hill, H. Gardiner, M.R.C.S.Eng., L.S.A., Pentillie, Leopold Road,
Wimbledon Pirk, London, S.W. 19.

1914. Hills, Harold William, B.S., M.B., B.Sc.Loud., M.R.G.S., L.R.C.P.Lond. ;

Lord Derby War Hospital, Warrington.

1907. Hine, T. Guy Macaulay, M.A., M.D., B.C.Cantab., 37, Hertford Street,

Mayfair, London, W. 1.

1909. Hodgson, Harold West, M.R.C.S., L.R.C.P.Lond., Assistant Medical
Officer, Severalls Asylum, Colchester.

1908. Hogg, Archibald, M.B., Ch.B.Glas., 54, High Street, Paisley, N.B.

1900. Hollander, Bernard, M.D.Freib., M.R.C.S., L.R.C.P.Lond, 57, Wimpole

Street, Loudon, W. 1.

1903. Hopkins, Charles Leighton, B.A., M.B., B.C.Cautab., Medical Superin¬

tendent, York City Asylum, Fulford, York.

1918. Horton, Wilfred Winuall, M.D.Edin., Medical Superintendent, Wye

House, Buxton.

1894. Hotcbkis, Robert D., M.A.Glasg., M.D., B.S.Durh., M.R.C.S., L.R.C.P.

Loud., M.P.C., Renfrew District Asylum, Dykebar, Paisley, N.B.
1912. Hughes, Frank Percival, M.B., B.S.Lond., M.ll.C.S., L.R.C.P.Lond., Thu
Grove, Pinner, Middlesex.

1900. Hughes, Percy T., M.B., C.M.Edin., D.P.H., Medical Superintendent,
Worcestershire County Asylum, Barnesley Hall, Bromsgrove.

1904. Hughes, William Stanley, M.B., B.S.Lond., M.U.C.S., L.R.C.P.Lond.,

Medical Superintendent, Shropshire County Asylum, Bicton Heath,
Shrewsbury.

1897. Hunter, David, M.A., M.B., B.C.Cantab., L.S.A., Medical Superintendent,
The Coppice, Nottingham. (Secretary for S.K. Divition, 1910-1913.)

1909. Hunter, Douglas William, M.B., Ch.B.Glasg., Assistant Medical Officer,

10, Halltield Bond, Bradford.

1912. Hunter, George Yeates Cobb, M.R.C.S., L.R.C.P.Lond., M.P.C.,

c/o Messrs. Grindlay A Co., 54, Parliament Street, London,
S.W. 1.

1904. Hunter, Percy Douglas, M.R.C.S., L.R.C.P.Lond., Three Counties

Asylum, Arlesey, Beds.

1888. Hyslop, Theo. B„ M.D., C.M.Edin., M.R.C.P.E., L.R.C.S.E., P.R.S.E.,
M.P.C., 5, Portland Place, London, W. 1.

1915. Ingall, Frank Ernest, F.R.C.S.Eng., L.R.C.P.Lond., D.P.H., Tue Brook

Villa, Liverpool.

1908. Inglis, J. P. Park, M.IL, Ch.B.Edin., Assistant Medical Officer,
Caterham Asylum, Caterham, Surrey.

1906. Irwin, Peter Joseph. L.R.C.P.AS.I., Assistant Medical Officer, District
Asylum, Limerick.

1914. James, George William Blomfield, M.B., B.S.Lond., The Lawn,
Hillingdon, Uxbridge.

1908. Jeffrey, Geo. Rutherford, M.D., Ch.B.Glas., F.R.C.P.E., M.P.C.,
Medical Superintendent, Bootham Park, York.

1893. Johnston, Gerald Herbert, L.R.C.P.AS.Ediu., L.R.F.P.&S.Glas., Brooke
House, Upper Clapton, London, N. 5.

1919. Johnston, Millicent Hamilton, B.A., M.B., B.Ch.Dub., Assistant Medical

Officer, Brentwood Mental Hospital, Essex.

1905. Johnston,Thomas Leonard, L.R.C.P.AS.Edin., L.R.F.PA.S.Glas.,Medical

Superintendent, Bracebridge Asylum, Lincoln.

1912. Johnstone, Emma May, L.R.C.P.AS.Edin., L.R.F.P.AS.Glas., M.P.C.,
Dipl. Psych., Holloway Sanatorium, Virginia Water, Surrey.

1878. Johnstone, J. Carlyle, M.l)., C.M.Glas., Melrose, Roxburgh.

1903. Johnstone, Thomas, M.D., C.M.Edin., M.R.C.P.Lond., Annandale,
Harrogate.

1880. Jones, D. Johnston, M.D., C.M.Edin.

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Original from

PRINCETON UNIVERSITY

Members of the Association. xvii

1879. Kay, Walter S., M.D., C.M.Edin., M.R.C.S.Eng., The Grove, Starbech,
Harrogate.

1886. Keay, John, C.B.E., M.D., C.M.Glasg., F.R.C.P.Edin., Medical Super¬
intendent, Hangour Village, Upliall, Linlithgowshire. (I’BKSIDBNT,
1918.)

1909. Keith, William Brooks, M.B., Ch.B.Abord., M.P.C.,81st Field Ambulance,
27th Division.

1908. Kelly, Richard, M.D., B.Ch.Dub., Assistant Medical Officer, Storthes
Hall Asylum, Kirkburton, near Huddersfield.

1907. Keene, George Henry, M.D., 14, Palmerston Park, Dublin.

1899. Kennedy, Hugh T. J., L.R.C.P.&S.I., Assistant Medical Officer, District
Asylum, Enniscorthy, Co. Wexford.

1897. Kerr, Hugh, M.A., M.D.Glasg., Medical Superintendent, Bucks County
Asylum, Stone, Aylesbury, Bucks.

1902. Kerr, Neil Thomson, M.B., C.M.Ed., Medical Superintendent, Lanark

District Asylum, Hartwnod, Shotts, N.B.

1893. Kershaw, Herbert Warren, M.R.C.S.Eng., L.R.C.P.Lond., 1, Stauhope
Road, Darlington.

1897. Kidd, Harold Andrew, C.B.E., M.R.C.S.Eug., L.R.C.P.Lond., Medical
Superintendent, West Sussex Mental Hospital, Chichester.

1916. Kilgarriff, Joseph O’Loughlin, A.B., M.B., B.Cb., B.A.O.Univ.,
Dublin, Assistant Medical Officer, County Asylum, Preatwich,
Lancs.

1903. King, Frank Raymond, B.A.Cantab., M.R.C.S.Eng., L.R.C.P.Lond.,

Medical Superintendent, Peckham House, Pcckham, London,
S.E.

1902. King-Turner, A. C., M.B., C.M.Edin., The Retreat, Fairford, Gloucester¬

shire.

1916. Kirwan, Richard R., M.B., B.Ch. R.U.I., Assistant Medical Officer,
West Riding Asylum, Meuston, Leeds.

1916. Kitson, Frederick Hubert, M.B., Cb.B.Leeds, Assistant Medical Officer,
West Riding Asylum, Wakefield.

1919. Knight, Mary Reid, M.A., M.B., Ch.B., Assistant Medical Officer,
Paisley District Asylum, Riccartsbar, Paisley, Scotland.

1903. Kough, Edward Fitzadam, B.A., M.B., I3.Ch.Dubl., Seuior Assistant

Medical Officer, County Asylum, Gloucester.

1898. Labey, Julius, M.R.C.S., L.R.C.P., L.S.A.Lond., Medical Superin¬
tendent, Public Asylum, Jersey.

1902. Langdon-Down, Percival L., M.A., M.B., B.C.Cantab., Normunsfield,
Hampton Wick, Middlesex.

1896. Langdon-Down, Reginald L., M.A., M.B., B.C.Cantab., M.ll.C.P.Loud.,
Normansfield, Hampton Wick.

1919. Langton, Peregrine Stephen Brackenbnry, M.R.C.S.Eng., L.R.C.P.Lond.,
M.B., B.S.Lond.., Assistant Medical Officer, York City Asylum,
Fulford, York.

1914. Ladell, R. G. Macdonald, M.B., Ch.B.Vict., The Gables, Killinghall,
Harrogate.

1919. Lathnm, Oliver, M.B., C.M.Sydney University, Pathologist, Lunacy
Department, Sydney, N.S.W. Permanent Address: Sydney
University, N.S.W.; Temporary Address: No. 1, Australian
Hospital, Sutton Verney, Warminster.

1909. Laurie, James, M.B., Ch.M.Glasg. ( Visiting Medical Officer, Asylum
and Poorhouse, Greenock, Smithson), Red House, Ardgowau Street,
Greenock, Renfrewshire.

1902. Laval, Evariste, M.B., C.M.Edin., The Guildhall, Westminster, London,
S.W. 1.

1898. Lavers, Norman, M.D.Brux., M.R.C.S., L.R.C.P.Lond. (Medical Super¬
intendent, Bailbrook House, Bath) ; Red Cross Military Hospital,
Moss Side, Maghull, near Liverpool.

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PRINCETON UNIVERSITY

Digitized by

xviii Members of the Association.

1892. Lawless, George Robert, F.R.C.S.I., L.R.C P.I., Medical Superintendent,
District Asylum, Armagh.

1870. Lawrence, Alexander, M.A., M.D., C.M.Aberd., 26, Hough Green,
Chester.

1883. Layton, Henry A., M.R.C.S.Eng., L.R.C.P.Edin., 26, Kimbolton Road,
Bedford.

1915. Leech, H. Brougham, M.D., B.Ch.Dub., Assistant Medical Officer,

County Asylum, Hatton, Warwick.

1909. Leech, John Frederick Wolseley, M.D., B.Ch.Dub., Assistant Medical
Officer, County Asylum, Devizes, Wilts.

1899. Leeper, Richard It., F.R.C.S.I., L.R.C.P.I., M.P.C., Medical Super¬
intendent, St. Patrick’s Hospital, Dublin. (Hon. Sec. to the Irieh
Division since 1911.)

1883. Legge, Richard J., M.D., R.U.I., L.R.C.S.Edin., “ Comcragh,” Leck-
hampton Road, Cheltenham.

1906. Leggett, William, B.A., M.D., B.Ch.Dubl., Assistant Medical Officer,
Royal Asylum, Sunnyside, Montrose).

1916. Lewis, Edward, L.R.C.P. & S.Edin., L.F.P. & S.Glasg., Cwirlai, Ty-Cross,

Anglesey.

1914. Lindsay, David George, L.R.C.P.&S.Edin., Senior Assistant Medical
Officer, Dundee District Asylum, West Green, Dundee.

1908. Littlejohn, Edward Salteine, M.R.C.S., L.R.C.P.Lond., Medical Super¬
intendent, Manor Mental Hospital, Epsom.

1898. Lord, Lt.-Col. John R., C.B.E., M.B., C.M.Edin., Medical Super¬
intendent, Horton Mental Hospital, Epsom. (Co-Editor oj Journal
since 1911; Assistant Editor of Journal, 1900-11.)

1906. Lowry, Jnmes Arthur, M.D., B.Ch., R.U.I., Medical Superintendent,
Surrey County Asylum, Brookwood.

1904. Lyall, C. *H. Gibson, L.R.C.P.&S.Edin., Leicester Borough Asylum,
Leicester.

1872. Lyle, Thomas, M.D., C.M.Glasg., 34, Jesmond Road, Newcastle-on-Tyue.

1906. Macarthur, John, M.R.C.S., L.It.C.P.Lond., Assistant Medical Officer,
Coluey Hatch Mental Hospital, London, N. 11.

1880 MacBryan, Henry C., L.R.C.P. & S. Edin., Kingsdown House, Box,
Wilts.

1900. McClintock, John, L.R.C.P.&S.Edin., Resident Medical Superintendent,

Grove House, All Stretton, Church Stretton, Salop.

1901. MacDonald, James H., M.B., Ch.B., F.R.F.P.&S.Glasg., Govan District

Asylum, Hawkhead, Paisley, N.B.

1884. MacDonald, P. W., M.D., C.M.Aberd., Grasmere, Spa Road, Weymouth.

(First Hon. Sec. S. W. Div. 1894 to 1905.) (President, 1907-8.)
1911. MacDonald, Ranald, M.D., Ch.B.Edin., London County Mental Hospital,
Bexley, Kent.

1905. MacDonald, William Fraser, M.B., Ch.B.Edin., M.P.C., 96, Pol worth
Terrace, Edinburgh.

1905. McDougall, Alan, M.D., Ch.B.Vict., M.R.C.S., L.It.C.P.Lond., Medical

Director, The David Lewis Colony, Sundlc Bridge, nenr Alderley
Edge, Cheshire.

1911. McDougall, William, M.A., M.B., B.C.Cuntab., M.Sc.Vict., 89, Banbury
Road, Oxford.

1906. McDowull, Colin Francis Frederick, M.D., B.S.Durh., Medical Superin¬

tendent, Ticehurst House, Ticehurst, Sussex.

1870. McDowall, Thomas W., M.D.Edin., L.R.C.S.E., “ Burwood,” Wadhurst,
Sussex. (President, 1897-8.)

1896. Macfarlane, Neil M., M.D., C.M.Aber., Medical Superintendent, Govern¬
ment Hospital, Thlotse Heights, Leribe, Basutoland, South Africa.

1902. McGregor, John, M.B., Ch.B.Edin., Senior Assistant Medical Officer,

County Asylum, Bridgend, Glam.

1917. Mclver, Colin, M.R.C.S., L.R.C.P., I.M.S., c/o Messrs. Grindlay & Co.,
Bombay, India.

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XIX

Members of the Association.

1914. Maekny, Magnus Ross, M.D., Ch.B.Edin., Newport Borough Asylum,

Cacrleon, Mon.

1917. Mackay, Norman Douglas, M.D., Ch.B., B.Sc., D.P.H.St. And., Dull-
Avon, Aberfeldy, Perthshire.

1915. McKenna, Edward Joseph, M.B., B.Cli., R.U.I., Assistant Medical

Officer, Carlow District Asylum.

1911. Mackenzie, John Cosserat, M.B., Ch.B.Edin., County Mental Hospital,
Burntwood, near Lichfield.

1891. Mackenzie, Henry J., M.B., C.M.Edin., M.P.C., Assistant Medical Officer,
The Retreat, York.

1903. Mackenzie, Theodore Charles, M.D., Ch.B., F.R.C.P.Edin., M.P.C.,

Medical Superintendent, District Asylum, Inverness.

1917. McMaster, Albert Victor, B.A., M.R C.S.Eng., “ The Mount,” Hills Road,
Cambridge.

1904. Mncnnmara, Eric Darners, M.A.Cauib., M.D., B.C., F.R.C.P.Lond., 87,

Harley Street, London, W. 1.

1914. Macncill, Celia Mary Colquhoun. M.B., Ch.B.Edin. (Pathologist, North-

field, Prestonpans); Leith War Hospital, Seafield, Leith.

1910. MacPhuil, Hector Duncan, M.A., M.D., Ch.B.Edin. (Assistant Medical

Officer, City Asylum, Gosforth, Newcastle-on-Tyne.

1882. Macphail, S. Rutherford, M.D., C.M.Edin., Derby Borough Asylum,
Rowditch, Derby.

1901. McRae, G. Douglas, M.D., C.M.Edin., F.R.C.P.Ed., Medical Super¬

intendent, District Asylum, Ayr, N.B. (Co-Editor of the Journal
since 1920; Assistant Editor 191(3-20).

1902. Macrae, Kenneth Duncan Cainerou, M.B., Ch.B.Edin. (Bangour Village,

Dechmont, Linlithgowshire); M.E.F.

1894. McWilliam, Alexander, M.A., M.B., C.M.Aber., Waterval, Odiham,
Winchfield, Hants.

1915. Manifold, Robert Fenton, M.B., D.Ch.Dub., Senior Assistant Medical

Officer, Denbigh Asylum, North Wales.

1908. Mapother, Edward, M.D., B.S.Lond., F.R.C.S.Eng., Maudsley Hospital,
Denmark Hill, S.E.6.

1903. Marnan, John, B.A., M.B., B.Cb.Dubl., Medical Superintendent, County

Asylum, Gloucester.

1896. Marr, Hamilton C., M.D., C.M., F.It.F.P.&S.Glasg., M.P.C., Commis¬
sioner in Lunacy (10, Succotli Avenue, Edinburgh). (Hon. See.
Scottish Division, 1907-1910).

1913. Marshall, Robert, M.B., Ch.B.Glas. (Assistant Medical Officer, Gartloch

Mental Hospital, Gnrtcosh, N.B.) ; 19th General Hospital, British
Expeditionary Force.

1905. Marshall, Robert Mncnab, M.D., Ch.B.Glasg., M.P.C., 2, Clifton Place,

Glasgow.

1908. Martin, Henry Cooke, M.B., Ch.B.Edin., Assistant Medical Officer,
Newport Borough Asylum, Caerleon.

1896. Martin, James Charles, L.R.C.S. & P.I., J.P., Assistant Medical Officer,
District Asylum, Letterkenny, Donegal.

1908. Martin, James Ernest, M.B., B.S.Lond., M.R.C.S., L.R.C.P.Lond.

Assistant Medical Officer, Long Grove Mental Hospital, Epsom,
Surrey.

1907. Martin, Mary Edith, L.R.C.P.&S.Edin., L.R.F.P.&S.GIas., L.S.A.Lond.,
M.P.C.Lond., Bailbrook House, Bath.

1914. Martin, Samuel Edgar, M.B., B.Ch.Edin., Barrister-at-Law (Senior

Assistant Medical Officer, St. Andrew’s Hospital, Northampton) ;
British Mediterranean Expeditionary Force.

1911. Martin, William Lowis, M.A., M.B., C.M., B.Sc., D.P.H.Edin., M.P.C.,

Dipl. Psvch. (Certifying Physician in Lunacy, Edinburgh Parish
Council), 56, Bruntsfiehl Place, Edinburgh.

1911. Mathieson, James Moir, M.B., Ch.B.Aber., Assistant Medical Officer,
Wadsley Asylum,Sheffield; 172, Wliitham Road, Broomhill, Sheffield.

1904. May, George Francis, M.D., C.M.McGill, L.S.A., Wiuterton Asylum,

Ferry hill, Durham.

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xx Members of the Association.

1912. Melville, William Spence, M.B., Ch.B.Glas., Woodilee Mental Hospital,
Lenzie, Glasgow.

1890. Menzies, William F., M.D.,B.Sc.Edin., M.R.C.P.Lond., Medical Superin¬
tendent, Stafford County Asylum, Cheddleton, near Leek.
(Pkksident-Elect.)

1877. Merson, John, M.A., M.D., C.M.Aber., Medical Superintendent, Borough
Asylum, Hull.

1893. Middlemass, James, M.A., M.D., C.M., B.Sc.Edin., F.R.C.P., M.P.C.,
Medical Superintendent, Borough Asylum, Ryliope, Sunderland.

1910. Middlemiss, James Ernest, M.R.C.S.Eng., L.R.C.P.Lond.; 131, North

Street, Leeds.

1883. Miles, George E., M.R.C.S., L.R.C.P.Lond., D Block, Royal Victoria
Hospital, Netley, Hants; British Empire Club, St. James’ Square,
London, S.W. 1.

1887. Miller, Alfred, M.B., B.Ch.Dubl., Medical Superintendent, Hatton
Asylum, Warwick. (Registrar since 1902.)

1912. Miller, Richard, M.B., B.Ch.Dubl., Stock, logatestone.

1893. Mills, John, M.B., B.Ch., Dipl. Ment. Dis., R.U.I., Medical Superinten¬
dent, District Asyium, Balliuasloe, Ireland.

1911. Moll, Jnn. Marius, Doc. in Arts and Med, Utrecht Univ., L.M.S.S.A.

Loud., M.P.C., Box 2587, Johannesburg, South Africa.

1913. Molyneux, Benjamin Arthur, B.A., M.D., B.Ch.Dubl., St. Helens

House, St. Helens, Hastings.

1910. Monnington, Richard Caldicott, M.D., Ch.B., D.P.H.Edin. (Darenth

Industrial Colony, Dartford, Kent) ; c/o Rev. T. P. Monnington,
Lowick Green, Ulverstou, Lancs.

1915. Monrad-Krohn, G. H., M.D., B.S., B.A.Christiania, M.R.C.S.Eng.,

M.R.C.P.Lond., M.P.C., Lecturer in Neurology at the University
and Physician to the Neurological Section of Rikshospitalet,
Christiania.

1914. Montgomery, Edwin, F.R.C.S.I., L.R.C.P.I. Dipl. Psycli. Manch., 1,

Tewkesbury Drive, Sedgeley Park, Manchester.

1899. Moore, Win. D., M.D., M.Ch.R.U.I., Medical Superintendent, Holloway
Sanatorium, Virginia Water, Surrey.

1914. Morres, Frederick, M.R.C.S.Eng., L.R.C.P.Lond. (Assistant Medical
Officer, Cane Hill Mental Hospital, Coulsdou, Surrey.

1917. Morris, Bedlington Howel, M.B., B.S. Durh., Inspector-General of
Hospitals, South Australia; Pembroke Street, College Park,
St. Peter’s, S. Australia.

1896. Morton, W. B., M.D.Lond., M.R.C.S., L.R.C.P.Lond., Medical Super¬
intendent, Wonford House, Exeter.

1896. Mott, Sir Frederick W., K.B.E., M.D., B.S., F.R.C.P.Lond., LL.D.Edin.,
F.R.S., 25, Nottingham Place, Marylebone, London, W. 1.

1896. Mould, Gilbert E., M.R.C.S., L.R.C.P.Lond., The Grange, Rotherham,

Yorks.

1897. Mould, Philip G., M.R.C.S.Eng., L.R.C.P.Lond., Overdale, Whitefield,

Manchester.

1914. Moyes, John Murray, M.B., Ch.B.Edin., D.P.M.Leeds, Tue Brook Villa,
Liverpool, E.

1919. Mules, Annie Shortridge, M.R.C.S., L.R.C.P., Assistant House-Surgeon,
Devon and Exeter Hospital; Court Hall, Kenton, near Exeter.

1907. Mules, Bertha Mary, M.D., B.S.I)urh., Court Hall, Kenton, S. Devon.

1911. Muncaster, Anna Lilian, M.B., B.Ch.Edin. (County Asylum, Chester);

home address, 8, Craylockhail Terrace, Edinburgh.

1917. Munro, Robert, M.B., Ch.B.Aberd., Assistant Medical Officer, Dorset
County Asylum, Dorchester.

1919. Murnane, John, L.R.C.P.I. & S.I. & L.M., Assistant Medical Officer,
Bnllinsloe Asylum, Ireland.

1916. Murray, Jessie M., M.B., B.S.Durlmm, 14, Endsleigh Street, Tavistock

Square, London, W.C. 1.

1909. Myers, Charles Samuel, M.A., D.Sc., M.D., B.C.Cantab., M.R.C.S.,
L.R.C.P.Lond., 30, Montague Square, W. 1.

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Members of the Association. * xxi

1903. Navarra, Norman, M.R.C.S., L.R.C.P.Lond., City n London Mental
Hospital, near Dartford, Kent.

1910. Neill, Alexander W., M.D., Ch.B.Edin., Warneford Mental Hospital,

Oxford.

1903. Nelis, William F.,M.D.Durb.,L.R.C.P.Edin.,L.R.F.P.&S.Glasg.,Medical
Superintendent, Newport Borough Asylum, Caerleon, Mon.

1869. Nicolson, David, C.B., M.D., C.M.Aber., M.R.C.P.Edin., F.S.A.Scot.,
201, Royal Courtsof Justice, Strand, London, W.C. 2. (Peesident,
1895-6.)

1888. Nolnn, Michael J., L.R.C.P.&S.I., M.P.C., Medicnl Superintendent,
District Asylum, Downpatrick.

1913. Nolan, James NoSl Green, M.B., B.Ch., A.B.Dub., The Hospital, Hel-

lingly Asylum, Sussex.

1909. Norman, Hubert James, M.B., Cli.B., D.P.H.Edin., Assistant Medical

Officer, Camberwell House Asylum, Peckham Road, London, S.E. 6.
(Home address: 61, Crystal Palace Park Road, Sydenham, London,
S.E. 26.)

1916. O’Carroll, Joseph, M.D., F.R.C.P., Physician Richmond and Whitworth
Hospitals; Lord Chancellor’s Medical Visitor in Lunacy; 43,
Merriou Square, Dublin.

1903. O’Doherty, Patrick, B.A., M.B., B.Ch.R.U.I., District Asylum,
Omagh. a

1918. Ogilvie, William Mitchell, M.B., C.M.Abcrd., Medical Superintendent,
Ipswich Mental Hospital, Ipswich.

1901. Ogilvy, David, B.A., M.D., B.Ch.Dub., Medical Superintendent, London

County Mental Hospital, Long Grove, Epsom, Surrey.

1911. Oliver, Norman H., M.R.C.S., L.R.C.P.Lond., Barrister-at-Law, Officer

in Charge, No. 4 Special Hospital for Officers, Latchmcre, Ham
Common, Surrey.

1892. O’Mara, Francis, L.R.C.P.&S.I., District Asylum, Ennis, Ireland.

1902. Orr, David, M.D., C.M.Edin., M.P.C., Pathologist, County Asylum,

Prestwich, Lancs.

1910. Orr, James H. C., M.D., Ch.B.Edin., Rosslynlec Asylum, Midlothian.
1899. Osburne, Cecil A. P., F.R.C.S., L.R.C.P.Edin., The Grove, Old Catton,

Norwich.

1914. Osburne, John C., M.B., B.Ch.Dubl., Assistant Medical Officer, Liudville,

Cork.

1890. Oswald, Landel R., M.B., C.M.Glasg., M.P.C., Physician Superin¬
tendent, Royal Asylum, Gartuavel, Glasgow.

1916. Ovcrbeck-Wright, Alexander William, M.D., Ch.ll., M.P.C., D.P.H.,
Superintendent, Lunatic Asylum, Agra, U. P., India (at present on
military duty); Lecturer on Mental Diseases, King George’s Hos¬
pital, Lucknow, and Agra Medical School, Agra. Address 12,
Rubislaw Terrace, Aberdeen.

1905. Paine, Frederick, M.D.Brux., M.R.C.S.Eug., M.R.C.P.Lond., Claybury
Mental Hospital, Woodford Bridge, Essex.

1898. Parker, William Arnot, M.B., C.M.Glasg., M.P.C., Medical Super¬
intendent, Gartloch Asylum, Gartcosh, N.B.

1898. Pasmore, Edwin Stephen, M.D., M.R.C.P.Lond., Chelsham House,

Chelsham, Surrey.

1916. Patch, Charles James Lodge, L.R.C.P.&S.Edin., Assistant Medical
Officer, Renfrew District Asylum, Dykebar, Paisley.

1899. Patrick, John, M.B., Ch.B., R.U.I., Medical Superintendent, Tyrone

Asylum, Omagh, Ireland.

1907. Peachell, George Ernest, M.D., B.S.Loud., M.R.C.S., L.R.C.P.Lond.,
M.P.C., Medical Superintendent, Dorset County Asylum, Herrison,
Dorchester.

1910. Pearn, Oscar Phillips Napier, M.R.C.S., L.R.C.P., L.S.A.Lond., Mental
Hospital, Banstead, Surrey.

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xxii Members of the Association.

1915. Pennant, Dyfrig Huws, D.S.O., M.R.C.S., L.R.C.P.Lond., Barn wood

House, Gloucester.

1913. Penny, Robert Augustus Greenwood, M.R.C.S., L.R.C.P.Lond., Devoii
County Asylum, Exminster.

1893. Perceval, Frank, M.R.C.S., L.R.C.P.Lond., Medical Superintendent,
County Asylum, Prestwich, Manchester. Lancashire.

1911. Petrie, Alfred Alexander Webster, M.D., B.S.Lond., Cli.B., F.R.C.S.

Edin., Assistant Medical Officer, Epileptic Colony, Epsom.

1878. Philipps, Sutherland Rees, M.D., C.M.Q.U.I., F.R.G.S., Bredon, Fisher
Street, Paignton.

1908. Phillips, John George Porter, M.D., B.S.Lond., M.R.C.S., M.R.C.P.Lond.,
M.P.C., Resident Physician aud Superintendent, Bethlem Royal
Hospital, Lambeth, Londou, S.E. 1.

1910. Phillips, John Robert Parry, M.R.C.S., L.R.C.P.Lond., Assistant Medical
Officer, City Asylum, Bristol.

1906. Phillips, Nathaniel Richard, M.D.Brux., M.R.C.S., L.R.C.P.Lond., Assis¬
tant Medical Officer, County Asylum, Abergavenny, Monmouth¬
shire.

1905. Phillips, Norman Routh, M.D.Brux., M.R.C.S., L.R.C.P.Lond., 67,
Billing Road, Northampton.

1891. Pierce, Bedford, M.D., F.R.C.P.Lond., Medical Superintendent, The
Retreat, York. (Hon. Secretary N. and M. Divirion 1900-8.)
(President.)

1888. Pieterseu, J. F. G., M.R.C.S., L.R.C.P.Lond., Ashwood House, Kingswin-

ford, near Dudley, Stafford.

1896. Planck, Charles, M.A.Camb., M.R.C.S., L.R.C.P.Lond., Medical Super¬
intendent, Brighton County and Borough Asylum, Haywards Heath.

1912. Plummer, Edgar Curnow, M.R.C.S., L.R.C.P.Lond. (Medical Superin¬

tendent, Lavorstock House, Salisbury); British Expeditionary Force.

1889. Pope, George Stevens, L.R.C.P.&S.Edin., L.R.F.P.&S.Glasg., Heighum

Hall, Norwich.

1913. Potts, William A., M.A.Camb., M.D.Edin.ABirm., M.R.C.S., L.R.C.P.

Loud., Medical Officer to the Birmingham Committee for the Care
of the Feeble-minded, 118, Hagley Road, Birmingham.

1876. Powell, Evan, M.R.C.S.Eng., L.S.A., Medical Superintendent, City
Lunatic Asylum, Nottingham.

1910. Powell, Jnmes Farqulmrson, M.R.C.S., L.R.C.P., D.P.H.Lond., M.P.C.,
Assistant Medical Officer, The Asylum, Caterham, Surrey.

1916. Power, Patrick William, L.R.C.P., L.R.C.S., Senior Assistant Medical

Officer, County Asylum, Chester.

1908. Prentice, Reginald Wickham, L.M.S.S.A.Lond., Beuuworth Manor,
Alresford, Hants.

1918. Prideanx, John Joseph Francis Engledue, M.R.C.S., L.R.C.P.Lond.,
Resideut Medical Officer, Graylingwell War Hospital, Chichester.
1901. Pugh, Robert, M.D., Cli.B.Edin., Medical Superintendent, Brecon and
Radnor Asylum, Talgarth, S. Wales.

1904. Race, John Percy, M.R.C.S., L.R.C.P., L.S.A.Lond., Journals aud
notices to Winterton Asylum, Ferryliill, Durham (Wheatley Hill,
Doncaster).

1899. Rainsford, F. E„ M.D., B.A.Dubl., L.R.C.P.I., L.R.C.P.&S.E., Resident
Physician, Stewnrt Institute, Palmerston, co. Dublin.

1894. Rambaut, Daniel F., M.A., M.D., B.Ch.Dtib., Medical Superintendent,
St. Andrew’s Hospital, Northampton.

1910. Raukine, Surg. Roger Aiken, R.N., M.B., 15.S., M.It.C.S., L.R.C.P.Lond.,
M.P.C.

1889. Raw, Nathan, C.M.G., M.P., M.D., B.S.Durli., L.S.Sc., F.R.C.S.Edin.,
M.R.C.P.Lond., M.P.C., 58, Harley Street, W. 1.

1870. Raynor, Henry, M.D.Aberd., M.R.C.P.Edin., Upper Terrace House,
Hampstead, London, N.W. 3. (President, 1884.) ( General

Secretary, 1877-89.) (Co-Editor of Journal 1895-1911.)

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1913. Read, Charles Stanford, M.D.Lond., M.R.C.S., L.R.C.P.Lond., Assistant

Medical Officer, Fisherton House, Salisbury.

1903. Read, George F., L.R.C.S.&P.Edin., Hospital for the Insane, New
Norfolk, Tasmania.

1899. Redington, John, F.R.C.S.&L.R.C.P.I., Portrane Asylum, Donabate.
Co. Dublin.

1911. Reeve, Ernest Frederick, M.B., B.S.Lond., M.R.C.S., L.R.C.P.Lond.,
Senior Assistant Medical Officer, County Asylum, Rainhill, Lancs.
1911. Reid, Dauiel McKinley, M.D., Cli.B.Glasg., Hawkhead Mental Hospital,
Cardonald, Glasgow.

1910. Reid, William, M.A.St. And., M.B., Ch.B.Edin., Senior Assistant Medical

Officer. Burntwood Asylum, Lichfield.

1886. Revington, George T., M.A., M.D., B.Ch.Dubl., M.P.C., Medical Superin¬

tendent, Central Criminal Asylum, Duiulrum, Ireland.

1899. Rice, David, M.D.Brux., M.R.C.S., L.R.C.P.Lond., D.P.H., Medical
Superintendent. City Asylum, Hillesdon, Norwich.

1897. Richard, William J., M.A., M.B., Ch.M.Glasg., Merryflats, Govan,
Glasgow.

1899. Richards, John, M.B., C.M.Edin., F.R.C.S.E., Medical Superintendent,

Joint Counties Asylum, Carmarthen.

1911. Roberts, Henry Howard, M.D., Ch.B.Edin., D.P.H.Glasg., Ennerdale,

Haddington, Scotland.

1914. Roberts, Ernest Theophilus, M.D., C.M.Edin., D.P.H.Camb., M.P.C.,

Hawkstone, 58, South Brae Drive, Jordauhill, Glasgow.

1903. Roberts, Norclifle, O.B.E., M.D., B.S.Durb., Senior Assistant Medical
Officer, Horton Mental Hospital, Epsom, Surrey.

1887. Robertson, Geo. M., M.D., C.M., F.R.C.P.Edin., M.P.C., Physician-Super¬

intendent, Koynl Asylum, Morningside, Edinburgh.

1908. Robertson, George Dunlop, L.R.C.S.&P.Edin., Dipl. Psych., Assistant
Medical Officer. District Asylum, Hartwood, Lanark.

1916. Robertson, Jane I., M.B., Cli.B.Glasg., Dogleap, Liinavady, Co.
Derry.

1895. Robertson, William Ford, M.D., C.M.Edin., 60, Northumberland Street,
Edinburgh.

1900. Robinson, Harry A., M.D., Ch.B.Vict., 140, Edge Lane, Liverpool.

1911. Robson, Copt. Hubert Alan Hirst, M.R.C.S., L.R.C.P.Lond., Punjaub

Asylum, India.

1914. Rodger, Murdoch Maun, M.D., Ch.B.Glas., The Rowans, Bothwell,
Scotland.

1908. Rodgers, Frederick Millar, M.D., Ch.B.Vict., D.P.H., Senior Medical
Officer, County Asylum, Winwick, Lancs.

1908. Rolleston, Charles Frank, B.A., M.B., Ch.B.Dub., Assistant Medical
Officer, County of London Manor Mental Hospital, Epsom.

1895. Rolleston, Lancelot W., C.B.E., M.B., B.S.Durh. (Medical Super¬
intendent, Middlesex County Asylum) ; Napsbury Mental Hospital,
Napsbury, near St. Albans.

1888. Ross, Chisholm, M.D.Syd., M.B., C.M.Edin., 151, Macquarie Street,

Sydney, New South Wales.

1918. Ross, Dermid Maxwell, M.B., Ch.B.Edin., Physician-Superintendent,
James Murray’s Royal Asylum, Perth.

1910. Ross, Donald, M.B, Ch.B.Edin., Argyll and Bute Asylum, Loch¬
gilphead.

1899. Rotherham, Arthur, M.A., M.B., B.C.Cantab., Commissioner under
Ment. Defec. Act, Board of Control, 66, Victoria Street, West¬
minster, London, S.W. 1.

1906. Rowan, Marriott Logan, B.A., M.D.R.U.I., Medical Superintendent,
Derby County Asylum, Mickleover.

1883. Rowland, E. D., M.B., C.M.Edin., 71, Main Street, George Town,
Demerara, British Guiana.

1902. Rows, Richard Gundry, C.B.E., M.D.Lond., M.R.C.S., L.R.C.P.Lond.

(Pathologist, County Asylum, Lancaster), Tooting Neurological
Hospital, Church Lane, Tooting, S.W.

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1877. Russell, Arthur P., M.B., C.M., M.R.C.P.Edin., Tlie Lawn, Lincoln.

1912. Russell, John Ivison, M.B., Cli.B.GlaRg., Jeanfield, 18, Woodend Drive,
Jordan Hill, Glasgow.

1915. Russell, William, M.B., Ch.B.Edin., Dip.Psych.Edin., D.T.M.Edin.,
Assistant Piiysician, Pretoria Mental Hospital, S. Africa.

1912. Rutherford, Cecil, M.B., B.Ch.Dubl.,‘Assistant Medical Officer, Holloway

Sanatorium, Virginia Water, Surrey.

1907. Rutherford, Henry Richard Charles, F.R.C.S.I., L.R.C.P.I., D.P.H., St.
Patrick’s Hospital, James’s St., Dublin.

189(5. Rutherford, James Mair, M.B., C.M.,F.R.C.P.Edin., M.P.C., Brislingtou
House, Bristol.

1913. Ryan, Ernest Noel, B.A., M.D., B.Ch.Dub., 6th Loudon Field

Ambulance (T.).

1902. Sail, Ernest Frederick, M.R.C.S., L.H.C.P.Lond., Medical Superinten¬
dent, Borough Asylum, Canterbury.

1908. Samuels, William Frederick, L.M.&L.S.Dubl., Medical Superintendent,

Central Asylum,Tangong, Rambutan.Perak,Federated Malay States.
1894. Saukey, Edward H. O., M.A., M.B., B.C.Cantab., Resident Medical
Licensee, Boreatton Park Licensed House, Baschurch, Salop.
Sankey, R. H. Heurtley, M.R.C.S.Eng., 3, Marston Ferry Road,
Oxford.

1873. Savage, Sir Geo. H., M.D., F.R.C.P.Lond., 26, Devonshire Place,
London, W. 1. (Late Editor of Journal.) (President, 1886.)
1906. Scanlan, John J., L.R.C.P.&S.Edin., L.R.F.P.AS.Glasg., D.P.H., 1, Castle
Court, Cornhill, Loudon, E.C. 3.

1896. Scott, James, M.B., C.M.Edin.. 98, Baron’s Court Rond, West Kensing¬
ton, London, W. 14.

1915. Scott, James McAlpine, M.D., Ch.B.Glasg., Junior Assistant Medical
Officer, Stirling District Asylum, Larbert.

1889. Scowcroft, Walter, M.R.C.S., L.R.C.P.I., Medical Superintendent, Royal
Lunatic Hospital, Choadle, near Manchester.

1911. Scroope, Geoffrey, M.B., B.Ch.Dub., Assistant Medical Officer, Central

Asylum, Dundrum.

1880. Seccombe, George S., M.R.C.S., L.R.C.P.Lond., c/o Messrs. H. S. King
and Co., 65, Cornhill, London, E.C. 3.

1912. Sergeant, John Noel, M.B., B.S.Lond., M.R.C.S., L.R.C.P.Lond., Medical

Superintendent, Newlands House, Tooting Bee Common, London,
S.W. 17. (Secretary South-Eastern Division since 1913.)

1913. Shand, George Eruest, M.D., Ch.B.Aber.; (Senior Assistant Medical

Officer, City Mental Hospital, Wiuson Green, Birmingham). Tem¬
porary address: 4, Odessa Road, narlesdcn, London, N.W. 10.
Permanent address : 307, Gilottt Hoad, Edgbaston, Birmingham.
1901. Shaw, B. Henry, M.B., B.Ch.R.U.I., Assistant Medical Officer, County
Asylum, Stafford.

1905. Shaw, Charles John, M.D., Ch.B., F.R.C.P.E., Medical Superintendent,
Royal Asylum, Montrose.

1915. Shaw, Hugh Kirkland, M.B., Ch.B.Edin., Assistant Medical Officer,
Stirling District Asylum, Larbert.

1917. Shaw, John Custance, M.R.C.S.Eng., L.R.C.P.Lond., Medical Superin¬
tendent, West Ham Borough Asylum, Goodmayes, Essex.

1904. Shaw, Patrick, L.R.C.P.&S.Ediu., Medical Superintendent, Hospital for
Iusane, Ararat, Victorin, Australia.

1909. Shaw, William Samuel J., M.B., B.Ch.R.U.I., Superintendent, North

Veravola, Poona, India.

1909. Shepherd, George Ferguson, F.R.C.S., L.R.C.P.Irel., D.P.H., 9, Ogle
Terrace, South Shields.

1900. Shera, John E. P., M.D.Brux., L.R.C.P.&S.Irel., Somerset County Asylum,
Wells, Somerset.

1912. Sheridan, Gerald Brinsley, M.B., B.Ch.R.U.I., Valkenbcrg Mental
Hospital, Cape Town, S. Africa.

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Members of the Association. xxv

1914. Sherlock, Edward Burball, M.D., B.Sc., D.P.H.Lond., Medical Superin¬
tendent, Darenth Industrial Colony, Dartford.

1914. Shield, Hubert, M.C., M.B., B.S.Durh., Assistant Medical Officer
Gutesliend Borough Asylum, Stannington, Newcastle-on-Tyne.

1877. Shuttlewortb, George E., B.A.Loud., M.D.Heidelb., M.K.C.S. and L.S.A.

Lond., 36, Lambolle Koad, Hampstead, London, N.W. 3.

1901. Simpson, Alexander, C.B.E., M.A., M.l)., C.M.Abcr., Medicnl Superin¬
tendent, County Asylum, Wiuwick, Newton-le-Willows, Lancashire.

1905. Simpson, Edward Swan, M.I)., Ch.B.Edin., East Biding Asylum,
Beverley, Yorks.

1888. Sinclair, Eric, M.D., C.M.Glasg., Inspector-General of Insane, Richmond
Terrace, Domain, Sydney, N.S.W.

1891. Skeen, James Humphry, M.B., Ch.M.Aber., M.P.C., Medical Super¬
intendent, Fife and Kinross District Asylum, Cupar, N.B.

1914. Slaney, Chas. Newnbam, M.R.C.S., L.R.C.P.Lond., The Elms, Parkhnret,
I.W.

1901. Slater, George N. O., M.D.Lond., M.R.C.S., L.R.C.P.Lond., Assistant
Medical Officer, Essex County Asylum, Brentwood.

1914. Smith, Charles Kelman, M.B., Ch.B.Ahord., Assistant Medical Officer,
Parkside Asylum, Macclesfield.

1910. Smith, Gayton Warwick, M.D.Lond., B.S.Durh., D.P.H.Cantab.,

M.R.C.S., L.R.C.P.Lond., Assistant Medicnl Officer, Springfield
Mental Hospital, Tooting, London, S.W. 17.

1905. Smith, George William, M.B., Ch.B.Edin., Chiswick House, Chiswick.
1907. Smith, Henry Watson, M.D., Ch.B.Aberd., Medical Superintendent,

Lebanon Hospital for the Insane, Asfurujeh, near Beyrout,
Syria.

1899. Smith, John G., M.D., C.M.Edin., Firbank, Burghill, Hereford.

1885. Smith, It. Percy, M.D., B.S., F.R.C.P.Lond., M.P.C., 86, Queen
Anne Street, Cavendish Square, London, W. 1. ( General Secretary,
1896-7. Chairman Educational Committee, 1899-1903.) (Presi¬
dent, 1904-5.)

1913. Smith, Thomas Cyril, M.B., B.Ch.Edin., County Asylum, Gloucester.

1911. Smith, Thomas Waddelow, F.R.C.S.Eng., L.R.C.P.Lond., M.P.C., Assis¬

tant Medical Officer, City Asylum, Mapperley Hill, Nottingham.

1884. Smith, W. Beattie, F.R.C.S.Edin., L.R.C.P.Ed'in., 4, Collins Street,

Melbourne, Victoria.

1914. Smith, Walter H., B.A., M.D., B.Ch.Dub., Senior Assistant Medical

Officer, County Asylum, Shrewsbury.

1899. Smyth, Walter S., M.B., B.Ch.It.U.I., Assistant Medical Officer, County
Asylum, Antrim.

1913. Somerville, Henry, B.Sc., M.R.C.S.Eng., L.R.C.P.Loud., F.C.S., Harrold,
Sharnbrook, Bedfordshire.

1885. Soutar, James Greig, M.B., C.M.Edin., M.P.C., 20, Royal Parade,

Cheltenham. (President, 1912-13.)

1906. Spark, Percy Charles, M.R.C.S., L.R.C.P.Lond., Medical Superintendent,

London County Asylum, Banstead, Surrey.

1875. Spence, J. Beveridge, M.D., M.C.Q.U.I., Medical Superintendent, Burnt-
wood Asylum, near Lichfield. ( First Regietrar, 1892-1899; Chair¬
man Parliamentary Committee, 1910-12.) (Pkksidbnt, 1899-

1900.)

1891. Stansfleld, T. E. K., C.B.E., M.B., C.M.Edin., Medical Superintendent,
London County Mental Hospital, Bexley, Kent.

1901. Starkey, William, M.B., B.Ch.R.U.I., Medical Superintendent, Borough
Asylum, Blackadon, Ivybridge, S. Devon.

1907. Steele, Patrick, M.D., Ch.B., M.R.C.P.Edin., Assistant Medical Officer,

District Asylum, Melrose.

1898. Steen, Robert H., M.D.Lond., M.R.C.P.Lond., Medical Superintendent,
City of London Mental Hospital, Stone, Dartford; Professor of
Psychological Medicine and Out-patient Physician, King’s College
Hospital. {Hon. Sec. S.E. Eivition, 1905-10; Acting Oen. Sec.
and Oen. Sec. 1915-19.)

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XXVI

Members of the Association.

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1914. Stephens, Harold Freize, M.R.C.S.Lond., L.R.C.P.Eng., 9, Belmont
Avenue, Palmer’s Green, Middlesex.

1914. Stevenson, George Henderson, M.B., Ch.B.Ediu., D.P.H.Lond., Joyce

Green Hospital, Hartford, Kent.

1912. Stevenson, William Edward, M.B., B.S.Durh., Winncell Down Camp,

Winchester.

1909. Steward, Sidney John, M.D., D.S.O., B.C.Cantab., M.R.C.S., L.R.C.P.

Loud., Assistant Medical Officer, Langton Lodge, Farneombe,
Surrey.

1915. Stewart, A. H. L., M.R.C.S., 72, Wimpole Street, London, W. 1.

1868. Stewart, James, B.A.Belf., F.R.C.P.Ed., L.R.C.S.I., “ Donegal,” 32,
Kingsmead Road, Tulse Hill, London, S.W. 2.

1913. Stewart, Rouald, M.B., Ch.B.Glasg., Gartloch Asylum, Gartcosh,

Glasgow.

1887. Stewart, Rotlisay C., M.R.C.S.Eng., L.S.A.Lond., Medical Superinten¬
dent, County Asylum, Narborough, near Leicester.

1914. Stewart, Roy M., M.B., Ch.B.Ediu. (Assistant Medical Officer, County

Asylum,Prestwich); Mediterranean Expeditionary Force c/o G.P.O.,
E.C. 1.

1905. Stilwell, Henry Francis, L.R.C.P.&S.E., Hayes Park, Hayes, Middle-

S6X.

1899. Stilwell, Reginald J., M.R.C.S., L.R.C.P.Lond., Moorcroft House, Hil¬

lingdon, Middlesex.

1897. Stoddart, William Henry Butter, M.D., B.S., F.R.C.P.Lond., M.R.C.S.

Eng., M.P.C., Harcourt House, Cavendish Square, London, W. 1.
{Hon. Sec. Educational Committee, 1908-1912.)

1909. Stokes, Frederick Ernest, M.D., Ch.B.Glasg., D.P.H.Cantab., Assistant
Medical Officer, Borough Asylum, Portsmouth.

1905. Strathearn, John, M.D., Ch.B.Glasg., F.R.C.S.E., 23, Magdalen Yard
Road, Duudee.

1903. Stratton, Percy Haughton, M.R.C.S., L.R.C.P.Lond., 10, Hanover
Square, Loudon, W. 1.

1885. Street, C. T., M.R.C.S., L.R.C.P.Lond., Haydock Lodge, Ashton,

Newton-le-Willows, Lancashire.

1909. Stuart, Frederick J., M.R.C.S., L.R.C.P.Lond., Senior Assistant Medical

Officer, Northampton County Asylum, Berrywood.

1900. Sturrock, James Prain, M.A.St.And., M.D., C.M.Edin., 25, Palmerston

Place, Edinburgh.

1886. Sufferu, Alex. C., M.D., M.Ch.R.U.I., Medical Superintendent, Rubery

Hill Asylum, near Bromsgrove, Worcestershire.

1894. Sullivan, William C., M.D., B.Ch.R.U.I., Hampton Criminal Lunatic
Asylum, Retford, Notts.

1918. Sutherland, Francis, M.B., Ch.B.Edin., Senior Assistant Physician, Royal

Asylum, Aberdeen.

1910. Sutherland, Joseph Roderick, M.B., Ch.B.Glasg., M.R.C.S., L.R.C.P.

Lond., D.P.H., County Sanatorium, Stonehouse, Lanarkshire.

1919. Suttie, Ian D.. M.B., Ch.B.Glas. (Assistant Medical Officer, Royal Asylum,

GlasgowT" 1055, Great Western Road, Glasgow.

1908. Swift, Eric W. 1)., M.B.Lond., Medicnl Superintendent, Government
Asylum, Bloemfontein.

1908. Tattersnll, John, M.D.Lond., M.R.C.S., M.R.C.P.Lond., Assistant
Medical Officer, London County Asylum, Hanwell, London, W. 7.
1910. Taylor, Arthur Loudoun, M.B., Ch.B., B.Sc., M.R.C.P.Edin., Craigend
Neurasthenic Hospital, Craigend Park, Liberton, Midlothian.

1897. Taylor, Frederic Ryott Percival, M.D., B.S.Lond.,M.R.C.S.Eng..L.R.C.P.

Lond., Medical Superintendent, East Sussex Asylum, Hellingly.
1918. Thienpout, Rudolph, M.D., Temporary Assistant Medical Officer, Cane
Hill Mental Hospital, Coulsdon, Surrey.

1908. Thomas, Joseph D., B.A., M.B., B.C.Cantab., Northwoods House, Winter¬
bourne, Bristol.

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Members of the Association. xxvii

1911. Thomas, William Reea, M.D., B.S.Lond., M.R.C.S., M.R.C.P.Lond.,
M.P.C., Mosside, Maghull, near Liverpool.

1880. Thomson, David G., C.B.E ., M.D., C.M.Edin., Medical Superintendent,

County Asylum, Thorpe, Norfolk. (President, 1914-18.)

1903. Thomson, Herbert Campbell, M.D., F.R.C.P.Lond., Assist. Physician
Middlesex Hospital, 34, Queen Anne Street, London, W. 1.

1905. Tidbury, Robert, M.D., M.Cli. R.U.I., Heath lands, Foxhall Road,

Ipswich.

1901. Tighe, John V. G. B., M.B., B.Ch.R.U.I., Medical Superintendent,
Gateshead Mental Hospital, Stannington, Northumberland.

1914. Tisdall, C. J., M.B., Ch.B., Tue Brook Villa, Liverpool.

1903. Topham, J. Arthur, B.A.Cantab., M.R.C.S., L.R.C.P.Lond., County

Asvlum, Chartham, Kent.

1896. Townsend, Arthur A. I)., M.D., B.Ch.Birm., M.R.C.S., L.R.C.P.Lond.,
Medical Superintendent, Hospital for Insane, Bnrnwood House,
Gloucester.

1904. Treadwell, Oliver Fereira Naylor, M.R.C.S.Eng., L.S.A.Lond., 90, St.

George’s Square, Loudon, S.W. 1.

1903. Tredgold, Alfred F., M.D., F.R.S.Edin., L.R.C.P.Lond. M.R.C.S.Eng.,
6, Dapdunc Crescent, Guildford, Surrey.

1908. Tuach-MacKenzie, William, M.D., Ch.B.Aberd., Medical Superintendent,

Royal and District Asylums, Dundee.

1881. Tuke, Charles Molesworth, M.R.C.S.Eng., Chiswick House, Chiswick,

W. 4.

1888. Tuke, John Batty, M.D., C.M., F.R.C.P.Edin., Resident Physician,

New Saughton Hall, Polton, Midlothian.

1915. Tulloch,'William John, M.D.St. Andrews, Director Western Asylums

Research Institute, 10, Claython Road, Glasgow.

1906. Turnbull, Peter Mortimer, M.C., M.B., B.Ch.Aberd:, Tooting Bee

Asylum, Tooting, London, S.W. 17.

1909. Turnbull, Robert Cyril, M.D.Lond., M.R.C.S., L.R.C.P.Lond., Medical

Superintendent, Essex County Asylum, Colchester.

1889. Turner, Alfred, M.I)., C.M.Edin., Plympton House, Plympton,

S. Devon.

1906. Turner, Frank Douglas, M.B.Lond., M.R.C.S., L.R.C.P.Lond., Medical
Officer, Royal Eastern Counties Institution, Colchester.

1890. Turner, John, M.B., C.M.Aberd., Medical Superintendent, Essex County-

Asylum, Brentwood.

1917. Vevers, Oswald Henry, M.R.C.S., L.R.C.P.Lond., Norton Vicarage,
Evesham.

1904. Vincent, George A., M.B., B.Ch.Edin.,Assistant Medical Superintendent,
St. Ann’s Asylum, Port of Spain, Trinidad, B.W.I.

1894. Vincent, William James N„ C.B.E., M.B., B.S.Durh., M.R.C.S.,
L.R.C.P.Lond., Medical Superintendent, Wndsley Asylum, near
Sheffield.

1914. Vining, Charles Wilfred, M.I)., B.S., M.R.C.P.Lond., D.P.H., M.P.C.,
Assistant Physician, Leeds General Infirmary, 40, Park Square,
Leeds.

1919. Waddell, Arthur Robert, M.D., C.M.Glasg., Deputy Commissioner,
Medical Services, Exeter Area; Roseland, Baldock, Herts.

1913. Walford, Harold R. S., M.R.C.S.Eng., L.R.C.P.Lond., Assistant Medical

Officer, Kent County Asylum, Banning Heath, Maidstone.

1914. Walker, Robert Clive, M.B., Ch.B.Edin., West Riding Asylum, Menston,

nenr Leeds.

1908. Wallace, John Andrew Leslie, M.I)., Ch.B.Edin., M.P.C., Mental
Hospital, Callan Park, Sydney, N.S.W.

1912. Wallace, Vivian, L.R.C.P. A S.I., Assistant Medical Officer, Mullingar
District Asylum, Mullingar.

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xxviii Members of the Association.

1889. Warnock, John, C.M.G.,M.D., C.M.,B.Sc.Edin., Medical Superintendent,
Abbasiyeh Asylum, nr. Cairo, Egypt.

1895. Waterston, Jane Elizabeth, M.D.Brux., L.R.C.P.I.,L.R.C.S.Edin.,M.P.C.,
85, Parliament Street, Box 78, Cape Town, South Africa.

1891 Watson, George A., M.B., C.M.Edin., M.P.C., Lyons House, Rainhill,
Liverpool.

1908. Watson,H. Ferguson, M.D.,Ch.B.Glas.,L.R.C.P.&S.E.,L.R.F.P.&S.Glas.,
D.P.H., 25, Palmerston Place, Edinburgh.

1910. Webb-Johnson, Cecil, M.B., Cb.B.Vict,, 150, Harley Street, W. 1.

1911. Webber, Leonard Mortis, M.R.C.S., L.R.C.P.Lond., Assistant Medical

Officer, Netherne, Merstham, Surrey.!

1919. Westrup, Joseph Perceval, M.R.C.S.Eng., L.R.C.P.Lond., Medical
Officer, Fisherton House Mental Hospital, Salisbury.

1919. Wheeler, Frederic Francis, M.R.C.S.Eng., L.R.C.P.Lond., Assistant
Medical Officer, Long Grove Mental Hospital, Epsom, Surrey.

1911. White, Edward Barton C., M.R.C.S., L.R.C.P.Lond., Senior Assistant

Medical Officer, Cardiff City Mental Hospital, Whitchurch, S. Wales.

1884. White, Ernest William, O.B.E., M.B.Lond., M.R.C.P.Lond., Betley

House, nr. Shrewsbury. (Hon. Sec. South-Eastern Division,
1897-1900.) ( Chairman Parliamentary Committee, 1904-7.)

(President 1903-4.)

1905. Whittington, Richard, M.A., M.D.Oxon., M.R.C.S., L.R.C.P.Lond.,
1, Eaton Gardens, Hove, Sussex.

1889. Whitwell, James Richard, M.B.,.C.M.Edin., Medical Superintendent,
Suffolk County Asylum (St. Audry’s Hospital), Melton, Suffolk.

1913. Wilkins, William Douglas, M.B., Cb.B.Vict., M.R.C.S., L.R.C.P.

Lond., County Mental Hospital, Cheddleton, Leek, Staffs.

1900. Wilkinson, H. B., M.R.C.S., L.R.C.P.Lond., Assistant Medical Officer,
Plymouth Borough Asylum, Blackadon, Ivybridge, South Devon.
1887. Will, John Kennedy, M.A., M.D., C.M.Aberd., M.P.C., Bethnal House,
Cambridge Road, London, N.E. 1.

1914. Williams, Charles, L.R.C.P. &S.Edin., L.S.A.Lond., Assistant Medical

Officer, The Warneford, Oxford.

1907. Williams, Charles E. C., M.A., M.D., B.Cb.Dubl.; Branksome Chine
House, Branksome Park, Bournemouth.

1905. Williams, David John, M.R.C.S., L.R.C.P.Lond., Medical Superintendent,
The Asylum, Kingston, Jamaica.

1915. Williams, Gwilym Ambrose, M.R.C.S.Eng., L.R.C.P.Lond., Pathologist

and Assistant Medical Officer, East Sussex County Asylum,
Hellingly.

1916. Wilson, Marguerite, M.B., Ch.B.Glasg., The Retreat, York.

1912. Wilson, Samuel Alexander Kinnier, M.A., M.D., B.Sc.Edin., F.R.C.P.

Loud., Registrar, National Hospital, Queen’s Squara, 14, Harley
Street, London, W. 1.

1899. Wolseley-Lewis, Herbert. M.D.Brux., F.R.C.S.Eng., L.R.C.P.Lond.,

Medical Superintendent, Kent County Asylum, Banning Heath,
Maidstone. ( Secretary Parliamentary Committee, 1907-12. Chair¬
man of same since 1912.)

1869. Wood, T. Onttersou, M.D.Durh., M.R.C.P.Lond., F.R.C.P., F.R.C.S.

Edin., 7, Abbey Crescent, Torquay. (President, 1905-6.)

1912. Woods, Janies Cowan, M.D., B.S.Lond., M.R.C.S., L.R.C.P.Lond.,
10, Palace Green, Kensington, London, W. 8.

1885. Woods, J. F„ M.D.Durh., M.R.C.S.Eng., 7, Harley Street, Cavendish

Square, London, W. 1.

1912. Wootton, John Charles, M.R.C.S.Eng., L.R.C.P.Lond., Haydock Lodge,
Newton-le-Willows, Lancs.

1900. Worth, Reginald, O.B.E., M.B., B.S.Durh., M.R.C.S., L.R.C.P.Lond.,

Medical Superintendent, Springfield Mental Hospital, nr. Tooting,
S.W. 17. ( General Secretary 1919.)

1917. Wright, Maurice Beresford, O.B.E., M.D., C.M.Edin. (118, Harley

Street, London, W. 1); 10, Palace Green, Kensington, London,
W. 8.

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PRINCETON UNIVERSITY

XXIX

Members of the Association.

1862. Yellowlees, David, LL.D.Glasg., M.D.Edin., F.R.F.P.AS.Glasg./'Grange-
neuk," Fountainball Road, Edinburgh. (Prbsident, 1890.)

1914. Yellowlees, Henry, O.B.E., M.D., Ch.B.Glasg., F.R.F.P.S.Glasg., 151,
Morningside Drive, Edinburgh.

1910. Younger, Edward George, M.D.Brux., M.R.C.P., M.R.C.8., L.8.A.Lond.,
D.P.H., Physician to the Finsbury Dispensary, 2, Mecklenburgh
Square, London, W.C. 1.

Ordinary Members . 626

Honorary Members . 26

Corresponding Members . 9

Total. 661

Members are particularly requested to send changes of address, etc., to The
General Secretary, 11, Chandos Street, Cavendish Square, London,
W. 1, and in duplicate to the Printers of the Journal, Messrs. Adlard
Sf Son if West Newman, Ltd., 23, Bartholomew Close, London, E.C. 1.

OBITUARY.

Honorary Members.

1887. Scliiile, Heinrich, M.D., Illenau, Baden, Germany.

1881. Tamburiui, A., M.D., lteggio-Emilia, Italy.

Members.

1869. Aldridge, Chas., M.I)., C.M.Aber., L.R.C.P.Lond., Bellevue House,
Plyuipton, Devon.

1902. Beale-Browne, Thomas Richard, M.R.C.S.Eng., L.R.C.P.Lond., c/o
P.M.O. Lagos, Nigeria, West Africa.

1897. Dove, Emily Louisa, M.B.Lond., 11, Jenuer House, Hunter Street,
Brunswick Square, London, W.C. 1.

1884. Drapes, Thomas, M.B.Dub)., L.II.C.S.I., Medical Superintendent, District
Asylum, Enuiscorthy, Ireland; “ Milleen,” Dalkey, Co. Dublin.
(Pbbsidhnt-BLBCT, 1910-11; Co-Editor of Journal since 1912.)

1917. Fearnsides, Edwin Greaves, M.D.Cainb., B.C., M.A., 46, Queen Auuo
Street, Cavendish Square, London, W. 1.

1891. Mercier, Charles A., M.D.Lond., F.R.C.P., F.R.C.S.Eng., lato Lecturer
on Insanity, Westminster Hospital; Moorcroft, Parkstone, Dorset.
(Secretary Educational Committee, 1893-1905. Chairman do. from
1905-12.) (President, 1908-9.)

1902. Watson, Frederick, M.B., C.M.Edin., Elm Lodge, Clay Hill, Enfield.

1883. Wiglesworth, Joseph, M.D., F.R.C.P.Lond., Springfield House, Wius-
combe, Somerset. (President, 1902-3.)

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PRINCETON UNIVERSITY

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PRINCETON UNIVERSITY

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PRINCETON UNIVERSITY

JOURNAL OF MENTAL SCIENCE, JANUARY, 1920 .

Charles Arthur Mercier, M.D.Lond., F.R.C.P.LoncL, F.R.C.S.Eng.
Obiit September 2 nd, 1919 . President 1908 - 9 .

Adlavd ¥ Son S* \\\st Xcxowan, Ltd.

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PRINCETON UNIVERSITY

THE

JOURNAL OF MENTAL SCIENCE

[Published by Authority of the Medico-Psychological Association
of Great Britain and Ireland.']

No. 272 [To’"""] JANUARY, 1920.

Vol. LXVI.

CHARLES ARTHUR MERCIER.

M.D.Lond., F.R.C.P.Lond., F.R.C.S.Eng. B. 1852 : d. 1919.

Only two years have passed since the death of one of the most
eminent of our scientific interpreters and teachers in the province of
mental diseases, and now another has gone from us whose intellectual
power and rare attainments were in many respects strikingly comparable
with those of Henry Maudsley. This likeness has doubtless been
already noted by many. It struck me some thirty-five years ago, at the
outset of my acquaintance with Mercier and some of his works and
from my knowledge of Dr. Maudsley’s writings, since the first edition of
his Physiology and Pathology of Mind was published in 1867. But
as the characteristics which these memorable men had in common
have probably never been noted in print, I venture here to make brief
mention of some of them. It would perhaps be as easy to draw a con¬
trast as a comparison, especially as regards some of their philosophical
views, their individual and social qualities, and their literary styles. But
my personal knowledge of Dr. Maudsley was not intimate enough to
fit me to speak on some of these points, and the others speak for themselves
in each author’s written works.

Both Maudsley and Mercier possessed in large measure the scientific
mind, and their works were marked alike by a dominant determination
to search out as thoroughly and explain as clearly and fully as their
powers allowed the subject they had chosen for the chief labour of their
lives. The terms they used were so clearly defined that their arguments
left but few gaps for strictly logical criticism, however unacceptable by
some their conclusions may have been. Both men were trenchant and
alert in controversy, and, perhaps in part consequence, neither was always
popular among those who were but slightly acquainted with them. In
their wide and intimate knowledge of the best of English literature both
excelled, and these and other acquirements, coupled with their excep¬
tional faculty of retentive memory, supplied them with rich stores of

CHARLES ARTHUR MERCIER,

[Jan.,

illustrations and examples which contributed largely to the charm and
clarity of their writings. Both, too, had a mass of readily quotable
knowledge of the Bible, Shakespeare, and numerous other classics, to
an extent not often attained even by purely literary specialists.

In making this short comparison I am reminded of the pleasure and
profit which I owe to the works of both Maudsley and Mercier. The
former impressed me early with a strong preference for the study of
subjects based on scientific knowledge rather than on tradition, while
Mercier’s writings on insanity, some time after I had taken to medical
work and was becoming interested in psychological medicine, gave me
the kind of guidance that I had been looking for in vain. And still,
after frequent re-readings, they seem to me to have achieved more com¬
pletely than any others the immensely difficult task of making plain,
to the serious beginner needing enlightenment, the many rough places
that obstruct the approach to knowledge of this attractive but perplexing
subject. But I am not intending here to compare these books with
other and larger works which abound in detailed information, and are
expressly written for those who specialise as alienist physicians.

Mercier spent his life in strenuous effort. In some respects his boy¬
hood recalls that of Charles Dickens. After a few years at Merchant
Taylors’ School he sought his own living by reason of family circum¬
stances, and engaged in various employments where he gained some
varied knowledge and experiences which stood him in good stead later.
During this time he went to sea as a cabin boy, and afterwards served
as a clerk in a London warehouse. Ultimately he was enabled to
commence medical-student life at the London Hospital when about
eighteen years old, and he qualified as M.R.C.S. four years later.
From this time forwards he was self-supporting. I have lately heard
from a distinguished surgeon, who was Surgical Registrar at the Hospital
when Mercier was House-Surgeon, that he was looked upon as exception¬
ally bright and thoughtful, giving promise of intellectual achievements
of no common order, and that when in after years he renewed his
acquaintance with Mercier, he “ marvelled greatly at his wide know¬
ledge of all sorts of subjects outside his professional work: general
literature, mechanics, agriculture, etc.” He adds, “I loved him, admired
him, and read everything written by him.”

At the London Hospital Mercier came especially under the influence
of Dr. Hughlings Jackson, and thus was led to study deeply the writings
of Herbert Spencer which greatly inspired Jackson’s thought and
work. Mercier was one of but two men I have known who read through
twice and carefully studied the whole of Spencer’s volumes. Knowledge
of this rare feat must have kindled even that calm philosopher’s enthu¬
siasm. It was no long time before Mercier’s natural bent towards
scientific thought and philosophy became fixed, and, as might have been

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expected, he devoted himself especially to his favourite studies and took
to alienism as his profession. After serving as a medical officer in some
large public asylums, he was, on the recommendation of Sir James
Crichton-Browne, appointed as resident physician to a private institu¬
tion which was in need of thorough reconstruction. Under his auspices
the institution was energetically reformed, removed from London to
Catford, in Kent, and carried on by him successfully for many years
until failing health obliged him to resign. For a few years he practised
in London, and finally went to Parkstone in Dorsetshire, where he
took private patients until a few years before his death.

During a period of over twenty years he suffered severely from the
pains and the progressive crippledom of osteitis deformans. In his later
years he was attacked by a deafness that at last was nearly total, and in
course of time by choroiditis, which for many months before his death
put a stop to reading and writing. He began, however, to write by
dictation, and persevered until a sharp onset of gout in the foot
followed promptly by diaphragmatic pleurisy was his almost sudden
death-blow; for his chest had for long stopped its breath-work.

Until about the last eight years, spent at Parkstone, Mercier held
many appointments, and did much public work of value. He was
Lecturer on Insanity at Westminster Hospital School of Medicine for
many years as well as at the London School of Medicine for Women ;
and later he held a similar post at Charing Cross Hospital, where he
was also Physician for Mental Diseases. At the London University he
was examiner on this subject. As a member of the Departmental
Committee on the Treatment of Inebriety, appointed by the Home
Secretary in 1908, he did good service, contributing in large measure to
the Report ; and his evidence given before the Royal Commission on the
Care and Control of the Feeble-minded on behalf of the Royal College
of Physicians was of considerable importance. His sound knowledge
and rare power of expressing himself with precision of language gained
him much credit when giving evidence in the Law Courts, and he was
for many years a prominent and welcome speaker at the Medico-Legal
Society. Mercier was also appointed by the College of Physicians to
deliver the Fitzpatrick Lectures on the History of Medicine in 1913
and 1914, his subjects being “ Astrology in Medicine ” and “Leper
Houses and Mediaeval Hospitals.”

It is needless for me to recite here any particulars of Dr. Mercier’s
long service and activity in connection with this Journal and the
Association, but I would call to remembrance the address he gave in his
year of Presidency, which was a very striking and thoughtful account of
his own attitude at that time towards the questions underlying the
problem .of the relation between body and mind.

He was married a second time after an interval of several years,

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and had the grievous fate to lose, only a few years before his death, the
much-loved wife to whom he had been married but two years.

In reviewing here the special qualities of Dr. Mercier as an alienist,
a scientific philosopher and a man of letters, I cannot attempt any
detailed or even adequate criticism of his numerous and varied works.
I have already indicated my judgment of him as an alienist physician
and teacher, and do not propose to speak much further under thjs head
in a journal among whose readers there are many more fitted than
myself to deal comprehensively with this part of the subject. But as I
am impressed with the belief that Mercier has been from time to
time more or less misunderstood, and therefore misrepresented, in
respect to one matter which seems to me of importance, I shall make a
brief endeavour to lessen or dispel the misunderstanding to which I
refer. I gather from what I have heard at some meetings of the
Association and have read long ago in medical journals, that from the
early time when Mercier began to insist on the primary importance of
concentrating on disorder of conduct in the diagnosis and interpretation
of insanity, he was frequently understood and quoted as meaning that
disorder of conduct was the primary pathological event in point of time
that ultimately led up to the diseased state known as insanity. In other
words it seems to have been sometimes implied that Mercier looked
upon disease of the mind as a result of disorder of conduct.

I am well aware that occasionally in the course of controversial
correspondence Mercier did not re-state in full the definition of insanity
which he had frequently reiterated in his writings and had persistently
set forth, as disorder of conduct always connoting disorder of mind and
brain and other organs. And when, on one of the occasions mentioned
above, he replied to his critic, “ When I say that insanity is primarily a
disorder, not of mind, but of conduct, I intend to state my doctrine,
not of conduct, but of insanity,” it is perhaps not very surprising that
his meaning, however clear it must have been to most readers, might
be somewhat obscure to others who were imperfectly acquainted with
Mercier’s previous writings, or had not taken the trouble to find out the
real point at issue.

However this may be, it is very plain even in his early writings that
he was insisting on the fact that disorder of mind could and did exist
without insanity; that disorder of conduct is of the first importance as
a sign of insanity, and often the sole sign, its accompaniments being
matters of inference only or mainly. Mercier, in a word, taught that a
man is rightly judged as insane from evidence of what he says and does,
not of what one may infer or guess that he thinks or feels.

As to how far Mercier’s teaching on this matter was original or not
mere opinions may differ. This question cannot be discussed here.
It appears to me, however, that at first he was criticised, not for talking

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platitudes, but for holding erroneous views; but that in later years, and
after his own reiterated statements that his views had not been accepted,
it was argued that, on the contrary, his views were common property
and required no assistance to recommend them. For myself I cannot
avoid the conclusion, based on the grounds above stated, that Mercier
was in this instance, as in all others, very far from thinking or even
talking platitudes when he issued his first work on insanity, and I feel
sure that genuine misconception on the part of some of his hearers
and his readers must have given rise to the question of the importance
and originality of his teaching in this respect. It is of course only
this last-named question which really concerns this memorial notice ;
and as, in common with many others, I hold the view that this part of
Mercier’s exposition of the scientific study of insanity is both original
and light-giving in a very notable degree, I have deemed it right to give
my own notion of this matter. Mercier was doubtless an eager disputant
on many questions of varying importance, when no point of scientific
moment was concerned, and sometimes plunged into controversy for
the mere pleasure of it. On such occasions he often allowed his
abundant wit and humour to have full play; and though in most of his
serious writings this tendency was duly restrained, it may have been
sometimes apparent in a context which rendered it liable to misinterpre¬
tation. But the bulk of his important works bears the true marks of
careful observation and sound reasoning, and demonstrates his single
aim to search out the truth in all questions into which he inquired.

As a philosophical student of scientific matters, especially in the
sphere of Psychology , Mercier’s rank was confessedly high. Yet he is
not readily classed as an adherent of any special school or 'ism. During
most of his life he was strongly influenced by the biological and psycho¬
logical tenets of Herbert Spencer. Thus he continued to hold, long
after the time when the work of Weismann and other biologists had
shown grounds for rejecting it, the doctrine of the strictly biological
transmission to offspring of characters specially developed in the life¬
time of parents. And his psychological writings, especially in their theo¬
retical aspect, were, like Maudsley’s, more or less coloured by these
views on questions of heredity and reproduction. But later in life he
became increasingly inclined to recognise more fully the part played
by training and experience, especially as regards the human mental
qualities, in the development of characters, and to regard all alike as
the joint product of a transmitted germinal tendency and of environ¬
mental action.

On the more speculative, but, with regard to the scientific study of
psychology, the more relevant question of the relation between bodily
and mental functioning, Dr. Mercier was, at least until his later years,
a confessed “dualist” or “epiphenomenalist,” and taught, with Spencer

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[Jan.,

and others, one doctrine of an “impassable gulf” between so-called
“mind” and so-called “matter.” (’)

Yet even on this much-debated question there were, I think, a few signs
in Mercier’s later writings and perhaps more in what he said in the
course of discussion, of his inclination towards the views which he had
formerly opposed. At any rate, Mercier was no blind follower of any
authority. He was an independent thinker, far more ready to modify
or abandon his opinions than some of his critics have supposed.

In noticing some of the most important of Mercier’s many other
books I must confine myself to mere indication of what I deem to be
their merits, without attempting any critical review.

His earlier work on the Nervous System and the Mind, which preceded
by several years his later and more widely known treatise on Psychology ,
Normal and Morbid, may still be regarded as a valuable exposition of
the subject, in which no one of any school of thought is likely to find
much cause for quarrel. It is especially adapted for readers beginning
their studies.

Much the same may be said of the book on Conduct and its Disorders,
Biologically Considered, in which the author estimates the various
modes and phases of human activity in the light of their value in secur¬
ing the survival of man in the struggle for existence. This book is
complementary to several others of Mercier’s works, and, though open
to criticism from some biological points of view, must take a high place
for its originality and practical value. It bears the mark of much study
and close thinking.

The work entitled A Neiv Logic consists of a detailed criticism of
both traditional and modern logic as taught in professional lectures and
treatises, as well as of an insistent setting forth of the distinction
between the “material’’argument on which action depends and by which
discovery is made, and the forming logic of postulation, in which the
proposition is formulated for the purpose of the argument. The book
has met with more blame than favour from specialists in logic, to some
extent apparently on the ground of the author’s alleged misunderstand¬
ing of the Aristotelian logic. I cannot venture to enter even into the
precincts of the modern logical arena, but will say only that at least the
constructive part of this book, on the science and art of reasoning, seems
to me of the highest worth to all intelligent students who desire to learn
how to think correctly. Much of its contents may be read with advan¬
tage in connection with the author’s book on Causation, presently to
be mentioned, in which there will be found an acute criticism on
J. S. Mills’ Canons of Induction, and also Mills’ whole treatment of
“ Causation.”

Mercier’s book on Causation and Belief, which of all his more
especially philsophical works I rank the highest in respect of sound

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BY SIR H. BRYAN DONKIN, M.D.

thinking, clear expression and practical value, must be passed over here
without any justification of my opinion of it. It appeared first in this
Journal in January and April, 1916, and subsequently was published in
book form by Messrs. Longmans & Co. Such a book was greatly needed.
The thoroughly practical chapter on “ Causes of Death and Causes of
Insanity” affords one out of many striking illustrations of the high value
of this book, and in itself may serve to contribute largely to the justifi¬
cation which space forbids me to attempt. The two books by Mercier
dealing with the legal and medical sides of the subject of crime and
criminals, entitled respectively Criminal Responsibility in the Insane
and Crime and Criminals , were both awarded (with an interval of ten
years) the Swimey Prize, which is given jointly by the Society of Arts
and the Royal College of Physicians for the best book on medical
jurisprudence. The first has been acclaimed widely by both legal and
medical authorities, and the second, in my judgment and that of many
others conversant with the subject, sets forth within comparatively small
compass one of the most comprehensive, careful and best-reasoned
expositions of the subject-matter with which I am acquainted. It is
written with truly scientific method and much knowledge of the material
dealt with. This work is destined to outlive for an indefinite time the
immense majority of all others devoted to the consideration of the
nature of crime and criminals.

A few more books, minor in point of size although not all of them in
relative importance, are well worthy of note. In his later years Mercier
took up strongly the subject of “modern spiritualism” and “telepathy,”
which he had hitherto deemed too insignificant for serious handling;
but, on the appearance of Sir Oliver Lodge’s reiterated announcement,
in the book entitled Raymond , that the facts alleged in evidence of
spiritualism had been proved scientifically , he proceeded to make a
careful study of the material published over a space of many years by
many writers on both sides of this question, including the Reports of
the Society for Psychical Research. Thereafter he wrote a book called
Spiritualism and Sir Oliver Lodge. This thorough and brilliant exami¬
nation of Sir O. Lodge’s method of inquiry and the complete confutation
of the claim he made for scientific proof of his conclusions was followed
not long afterwards by an inimitably close parody of the spiritualistic
reasonings of Sir Oliver Lodge and others, with the title of Spirit Experi¬
ences, to which as a sub-title the publisher added, Or the Conversion of a
Sceptic. This contained numerous references to the doings of “mediums,”
well known and widely advertised in spiritualistic writings, and was
aptly complementary to Mercier’s previous counterblast to the
Professor’s book. But the pamphlet seems to have grievously misled
several “ spiritualists ” and believers in “ telepathy,” as well as other
reviewers, the former welcoming the author as a deserter from “ ortho-

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8 CHARLES ARTHUR MERCIER, [Jan.,

dox ” science to their own ranks, and some of the latter deploring the
mental breakdown that could alone, as they deemed, account for this
great lapse of a “distinguished scientist.” This jeu cTcsprit cannot fail
to call to the minds of some of us an occasion when Mercier ventured to
read a paper before the Medico-Psychological Association on the Inter¬
pretation of Dreams, when his subtle parabolic essay was at first mis¬
construed by some, but at last, as its meaning appeared, brought down
upon the reader some measure of disapproval for its ill-placed levity.

To speak duly of Mercier as a man of letters is beyond my present
scope. His style varied considerably with his subject-matter, but it
was ever noticeable for its pure, unpretentious and incisive English.
He wrote with great rapidity; but in his larger works, and indeed most
others, he pruned and corrected much, frequently re-writing them in
part and sometimes wholly. In his choice of the right word, for the
sake of both accurate expression and literary form, he may be held to
have rivalled such masters of writercraft as R. L. Stevenson and
Flaubert. But under the easy and clear flow of his sentences the
linguistic precisian that he really was lay very deeply hidden.

Before ending this attempt to estimate the qualities of Dr. Mercier I
venture to give the following quotations, the one from an appreciation
kindly sent me by a literary friend of his and mine, Mr. Herbert
Allport, the other from a short notice of him written by Sir William
Osier, and published in the British Medical Journal in September,
1919.

Mr. Allport, who is the Secretary of an old-established club known
as “ The Casual,” which meets for frequent informal discussions on all
kinds of subjects, and of which Mercier was for many years one of the
brightest members, writes thus : “ There was no man of letters whom
Mercier loved better than Dr. Johnson, and there was no man whose
sayings he quoted more frequently. He had much in common with his
hero: the same fearlessness in controversy, the same sturdy common
sense, the same trenchancy of expression, the same wide and varied know¬
ledge, the same pugnacity, and sometimes, perhaps, the same disposi¬
tion to talk for victory . . . Whenever I was in straits for a paper at

the Casual Club I used to write to him for help. By return of post he
answered—‘ You can put me down for any date you like.’ He
might almost have added, ‘ for any subject you like,’ for there were few
with which he was not able and willing to deal . . . Usually, when

a man asks you for criticism it means that he is asking you for praise.
Mercier not only accepted criticism with the readiest good humour, but
was always willing to modify what he had written if he thought you had
made out your point . . . He wrote many books on many subjects,

and the subjects, within certain limits, modified the style. There were,
however, three characteristics which were never absent. The first

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and most important was the lucidity of thought and expression. The
second was the purity of the English. The third, which I have not seen
mentioned elsewhere, was the abundance and felicity of the examples and
illustrations. A fourth characteristic—the humour and sarcasm which
distinguished him—was less uniformly manifested; but whether they
were rigidly held in check or displayed with freedom, humour and
sarcasm were always at his command. Mercier was the most many-
sided man whom I have known with intimacy, and probably everyone
who came in close contact with him could contribute some fresh trait
of intellect or character. His knowledge of general history and
literature was astonishing in one whose attention had been chiefly given
to other studies. He had a few minor foibles, but there was no one
whom I admired so greatly, and I shall always be proud that he was
willing to regard me as a friend.”

Sir William Osier writes thus of Mercier : “ Though not of Oxford,
and a sharp critic of her methods, the University had a great fascination
for him, and of late years he not infrequently would spend a few days
at the Randolph seeing old friends. It was a rare treat to have him
dine in Hall, and afterwards, in Common Room, start a discussion on
the need of reform in our methods of education. He had very clear
and sound views, and argued with great ability upon the uselessness of
logic as at present taught. He delighted to shock the classical don
by unmeasured abuse of Aristotle, whose methods, he claimed, had done
irreparable damage to the human mind. With a rich vocabulary and
a keen wit he had no equal among us as a controversialist. He
was best with a few friends after dinner, with enough port, as he would
say, to quiet his gout. When last with me, a few months ago, he was
in fine form—I never saw such a triumph of mind over matter—and
entertained us with stories of his student life and anecdotes of
Hughlings Jackson and Jonathan Hutchinson. Maitre Francois must
have been a man of this type, and Mercier’s trick of tongue was racial.
Controversy he loved, and, strange to say, it brought him friends;
despite the caustic pen, he had a warm, generous heart. The courage
with which he bore his many infirmities is a lesson to us all. Never
complaining, he worked on to the end, and went down, as he promised,
with all the ‘flags flying.’ We shall miss the brilliant critic of our ways
and words.”

I would add but little on my own account to the words of these
discerning critics. However, on some occasions, Mercier’s readiness
to engage in controversy and his great joy of battle may have brought
him into sharp conflict of wit with some who misunderstood him, and
others who disagreed with his views know that he was a man innocent
of all rancour.( 3 ) He never nursed a grudge, and always assumed that
those with whom he disputed were as ready as he was himself to take

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impersonally the passes and hits of argumentative encounters. In this
assumption, however, he was occasionally mistaken, and perhaps he
was sometimes himself to blame for being misunderstood. He may
have had some enemies, but he numbered troops of friends. He was
straightforward, fearless, warm-hearted and ever trustworthy. His
abounding courage inspired him to fight down depression in many
seasons of great trouble, and throughout that period of more than
twenty years when his life might be truly called “a long disease.”

Among several able and untiring workers I have personally known
who bravely and cheerfully laboured on to the end there was but one
other whose many struggles, pains and sorrows could be fittingly matched
with his. He alone of them could.have rightfully endorsed these
verses by that other who was the maker of them :

“ In the fell clutch of circumstance
I have not winced nor cried aloud,

Under the bludgeoning of chance
My head is bloody, but unbowed.

“ It matters not how strait the gate,

How charged with punishment the scroll,

I am the master of my fate ;

I am the captain of my soul.”

. H. Bryan Donkin.

(') Here he differed widely from Maudsley, whose writings clearly show him to
have been a scientific materialist, and a direct successor, equipped with modern
physiological knowledge, to the French encyclopaedist philosophers, such as d'Hol-
bach and Cabanis; himself, it may be added, to be succeeded by Mr. Hugh Elliot,
the author of the newly-published and weighty book on Modern Science and
Materialism .—( ! ) As one instance out of several where strenuous scientific disputes
in journals led to subsequent acquaintance and ultimate friendship I would record
that one of the warmest of Mercier’s opponents was appointed by him as his.
literary executor.

Part I.—Original Articles.

The Need for Schools of Psychiatry. By C. Hubert Bond, D.Sc.,
M.D.Edin., F.R.C.P.Lond., Commissioner of the Board of Control
and Emeritus Lecturer in Psychiatry at the Middlesex Hospital
Medical School.

In their fourth Annual Report, published in 1918, the Board of
Control drew attention —not for the first time, but in more extended
form than hitherto—to deficiencies in the arrangements, as at present
organised, for the treatment of persons suffering from mental disorder,

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especially in its incipient and early stages; to the insufficiency of
attention paid at medical schools (*) to this important branch of medical
science with its consequent ill-effects both to patients and to the
medical profession; and to the absence of any special qualification in
psychiatry, as a requirement for the higher medical posts in public
institutions for the insane, such as is demanded in public health of
medical officers of health of areas of above a stated size.

That these deficiences could not be made good without amendment
of the existing law was recognised, and accordingly a series of
recommendations in this direction were included in the report. As
some of these are sub judice , it is not proposed on this occasion to refer
to them, or, other than by way of their desirability as at least adjuncts
in a school of psychiatry, to the establishment of clinics for mental
as well as other neurological cases (including beds as well as an out¬
patient department).

(A) Clinics.

(t) Their Necessity for Mental Cases.

With respect to these clinics, it is, however, submitted that, whether
as independent units or—and, it is suggested, preferably—at or closely
affiliated with general hospitals, they should be regarded absolutely
indispensable as an integral part of the clinical facilities of every
medical school (a) if this branch of medicine is to be taught adequately
to its importance, both in the students’ curriculum and after qualifying
in medicine, and (b) if it is to receive study and research on organised
lines, without which progress cannot be other than intermittent and
spasmodic. A third reason (c) for their indispensability will be men¬
tioned a little later on.

The grounds of the hitherto prevailing disinclination of general
hospitals to shoulder this additional burden, quite apart from financial
considerations, are not difficult to understand, and, indeed, command
sympathy.( 8 ) But the significance of the mental element in diseases not
classified as of the nervous system—even in surgical affections—is
happily receiving increasing attention ; and it is to be hoped that the
day is not far distant when no general hospital staff will be deemed
complete without a physician possessing expert knowledge in psychiatry:
especially is this the more probable, firstly as the necessity of specialism
becomes more admitted, and secondly, and by implication, as apprecia¬
tion grows of the advantage of all forms of expert knowledge being
readily available for each patient—in short, the benefit of what is
frequently referred to nowadays as “ team-work.”

If an interpolation will be pardoned, and though not part of my theme,
it may be remarked that consistency requires that this doctrine, once

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accepted, should be applied to the medical administration of all our
institutions for the insane; and that their arrangements should provide
that to the physicians of those institutions, regarding themselves as
primarily mental experts, and for consultation with them experts in
other branches should be available—not merely in emergency, but
as part of the routine consideration of at least the recent cases and
others in need of active treatment. This suggestion may savour of the
unattainable ideal, and so, indeed, having regard to the situation of
certain of the institutions, it must for a considerable time to come
probably remain; but, as respects a fair proportion of them, it could,
if desired, be attained even now—indeed, examples are not wanting
of partial attempts thereat.

(2) Their Affiliation with General Hospitals.

With that digression, let me return to and complete what, for the
purposes of this paper, is requisite to be said as to clinics to which
mental cases are admitted. The third reason for their necessity and—
as is now submitted—for their affiliation with general hospitals is ( c ) the
reluctance of sufferers from premonitory and early symptoms of mental
breakdown either to present themselves for advice at the out-patient
department of, or submit themselves to treatment in, a hospital, which—
res ipsa loquitur —labels the patient as the subject of a nervous or mental
ailment. Perhaps some day, when our profession is more skilled in the
differential diagnosis of the forms of mental disorder, can with greater
precision assert what these and those premonitory symptoms signify, and
can offer encouragement with the voice of certainty, an end will be made
of this prejudice, which at present is moreover only too often stimulated
by attempts to draw minatory inferences from misleading and ill-digested
statistics of heredity. Till that day arrives, the most promising hope of
breaking what in reality is a vicious circle of obstacles to treatment and
advancement of knowledge in the subject is an invitation and welcome
from general hospitals to all persons so suffering, coupled with adequate
arrangements, reasonably limited as to extent, for the in-patient treatment
of severer but recoverable mental cases. There is abundant evidence
that such persons, either at their own initiative or by the action of their
friends, are willing to go for treatment to a hospital that is general in
its medical functions; for they realise that privacy as to the nature of
the ailment is possible, and that the prejudice they fear need not be
aroused. Arrangements for outpatients .—Out of these arguments arises
my strong opinion that, to attain the fullest measure of success, the
out-patient department of such a clinic should not be at the clinic but
should form one of the sections, and be manifestly a part of the
general out-patient department of the hospital.

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BY C. HUBERT BOND, D.SC.

(3) Their Relation to Other Clinical Units .

Furthermore, and to complete the picture as to the position a clinic
admitting mental cases should occupy in the clinical arrangements of a
medical school and as an integrant of a school of psychiatry, its structural
and other needs—about which I should like to say something on another
occasion—practically demand that it should be somewhat if not entirely
an entity. On the score of prejudice, that necessity imports a danger
which, if possible, should be avoided. Here, again, probably the most
promising method is to take advantage of the policy proposed or being
pursued by several general hospitals towards meeting their needs for
extension; whereby, in lieu of attempting to enlarge the existing
structure, arrangements are made to treat certain types of patients in
separate units erected on a site where land is liberally available—their
administration forming part of that of the parent building with which,
by the latter’s name being extended to them, their identity is maintained.

Clearly the mental clinic, as respects in-patient treatment, should
form one of these units. To this effect definite proposals have been
made and schemes are in preparation. To cite them might be
premature; but if any present here this afternoon feel at liberty to do
so, more specific information than can be found in my remarks would
doubtless be an encouragement elsewhere.

If yet one other interpolation is permissible, and before passing from
the question of these clinics for mental cases, it is my desire to enter a
friendly but strong protest against a readiness on the part of some of those
who welcome the advent of these clinics to relegate existing institutions
for the insane—truly not without an expression of regret—to the
role of providing for the care and nursing of irrecoverable cases : if
rightly understood, verily a noble duty calling out great qualities and
demanding much self-sacrifice; but such a divorce from incentive to
treat to recovery would be medically depressing to an extreme degree,
and would cause these institutions to be pervaded with a most prejudicial
feeling of helplessness. It is scarcely necessary to labour the point, as
it is most unlikely that the clinics, whether as parts of medical schools
or scattered more widely, will ever be able to meet the needs of all
recent cases requiring asylum treatment and of all those that are in
point of fact recoverable.

(4) Their Functions in Relation to Mental Cases.

On the other hand, these clinics, as respects their provision for
mental cases, should aim at fulfilling three main functions, and should
afford—

(1) Therapeutic facilities (a) for that proportion of recent and recover¬
able cases (whether certifiable or not, but not certified) upon whom

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14 the need for schools OF PSYCHIATRY, [Jan.,

existing arrangements press most hardly, and (h), in their section of the
general out-patient department, for incipient uncertifiable cases and for
certifiable cases in their early stages, so many of whom, through lack
of treatment, have to face life’s difficulties with a continuous feeling of
self-insufficiency.

(2) Better educational facilities during the medical curriculum,

enabling the student constantly to appreciate the relationship between
psychological and general medicine; but even these facilities will be
incomplete without the clinical material of the neighbouring public
asylum, between which and any school of psychiatry it is most important
that there should certainly be always a close link ; and-

(3) A centre for both laboratory and clinical research and post¬
graduate study, for without these such a school must be barren.

If they can successfully make these provisions they will abundantly
fulfil the brightest hopes that can reasonably be entertained of them.
Per contra , without their establishment and, as I believe, without their
affiliation to general hospitals, a number, difficult to estimate but by no
means negligible, of persons, the subject of various neuroses and mental
ailments, will continue untreated to carry on their daily tasks to their
own dissatisfaction and to the detriment of themselves and society.

(B) Diplomas in Psychological Medicine.

(1) Their Institution , 1908-12.

Most of us here to-day must have a lively recollection of the stimula¬
ting effect of the paper ( 3 ) read at the May Quarterly Meeting in 1908
by Lieut.-Col. D. G. Thomson. In it he laid bare the position and
powerfully advocated a series of measures, including the establishment
of diplomas, to combat the absence in this country of an adequate
scheme of instruction in the institutes and practice of psychiatry. The
movement that ensued is so closely associated with his name that it is
only with diffidence that another can take up its threads; and though
his goodwill has been secured in advance, my intervention is only the
result of representations that now, at the end of a decade since the
initiation of the proposals, a stocktaking of progress is due, that the
time is ripe for further representations to the bodies concerned and
of an assurance from the Secretary that this communication on the
subject will be welcome.

It will also be recalled that Col. Thomson’s paper, and a resolution (*)
which he moved at the annual meeting in the same year, led to the
appointment of a sub-committee ( 6 ) of the Educational Committee to
consider the matter in detail; and that ultimately a highly important
circular letter, ( 6 ) signed by the then President, the late Dr. Mercier,
was forwarded to each of the Universities and other medical examining

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bodies in the United Kingdom. In making their recommendations,
the Association formulated a carefully-considered syllabus of instruc¬
tional courses which, it was suggested, should lead up to the establishment
of diplomas in psychiatry.

Within the ensuing two years gratifying action was taken by five of
the Universities—Manchester, Leeds, Edinburgh, Cambridge and
Durham—each of which, in the order enumerated, passed regulations
for a diploma after attendance on approved courses and examination in
prescribed subjects. A perusal of these five sets of regulations shows
that the Association’s suggestions have been largely adopted; but
though they present many points of agreement, in several particulars
they differ considerably. In the hope that it may be of some service, a
summary of their similarities and differences is herewith appended. It
is not, however, intended to allude to these in any way seriatim, and
only in so far as it is desired to offer comments upon them.

(2) Obstacles to Progress.

That the action taken by these five Universities was a step of deep
import to our specialty no one will gainsay ; and if its immediate results
have been meagre and perhaps disappointing,to its authors—for, in
truth, less than a score of candidates have taken these diplomas—any
settled feeling of discouragement or disillusionment would be unjustified
and betoken ignorance of the facts. In the first place, the war caused
a partial if not entire cessation of the qualifying courses, and swept into
the naval and military services wellnigh all the men who might have
been tempted to proceed to one of these diplomas; and secondly, the
interval (from two to four years) between their institution and the out¬
break of war brought into prominence obstacles, from which—if the
truth is to be told and one may say so without offence—some lack of
enterprise and of appreciation of the responsibility incurred in attempt¬
ing to treat those mentally ill cannot be wholly excluded. But if in one
direction the war had a retarding influence, there is encouraging evidence
that in other ways it has had a quickening influence. It has taught us
many lessons : in our profession generally, the efficacy of special training
and of the real expert’s skill; in our particular branch of treatment, that
there is need of much more of the purely medical element; and above
all, the need to be up and doing and to give of our best. These are
lessons which inspire confidence that obstacles of a personal nature
need not be feared.

There are, however, difficulties connected with the circumstances in
which asylum physicians are placed (situation of the institution, need for
study-leave, uncertainty of prospects, etc.) which merit careful attention.
My colleagues, ever since the institution of these diplomas, have watched
the movement with interest and sympathy, and, impressed with its

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16 THE NEED FOR SCHOOLS OF PSYCHIATRY, [Jan.,

importance, the Board included in the recommendations already referred
to one to the effect that the possession of a diploma in mental diseases
should ultimately be obligatory upon the holders of the higher medical
posts on the staffs of institutions for the insane. In the meantime and
in the absence of any such enactment they have given further careful
consideration to the matter, and feeling that the remedy for at least
some of the principal difficulties is within the discretional powers of
Visiting Committees, the Board contemplate the issue of a circular
letter to those bodies. It would be improper to anticipate the details
of that letter; but, for the purposes of my argument, let us assume all
circumstantial difficulties can be and, with mutual goodwill, will be
removed.

(3) Their Scope , and Some Suggestions.

Upon the scope of the diplomas, especially as at least one of
them is under revision, it is desired to raise the following points for
consideration:

(1) As to their description, three of them are termed “—in Psycho¬
logical Medicine,” the other two being “—in Psychiatry.” It is very
doubtful if the latter term can now be deemed sufficiently wide in its
ambit; the former is probably to be preferred, and it moreover lends
itself to the use of the letters D.P.M. by way of abbreviation—a triviality
perhaps, but not without importance.

(2) It seems a pity that each does not lay down a minimum period,
subsequent to obtaining a registrable qualification, before which
the examination cannot be completed— e.g., two years.

(3) It is highly desirable that the regulations and syllabus of each
should plainly indicate the University term or terms during which each
course (whether systematic or practical) is available, with the days and
hours sufficiently set out to enable candidates to ascertain their ability
to attend.

(4) A statement, clearer than is always to be found, would be
appreciated as to the minimum extent to which the whole curriculum for
the diploma must be attended at the University in question. This can
be expressed as so many of the total number of terms required for the
full curriculum, or as so many courses out of the total number of subjects
(the plan already adopted in two instances), or in the alternative. Two
of the five Universities do not apparently insist on any local attendance.
If criticism is permissible, this latitude, though not without its con¬
venience in existing circumstances, seems to be regrettable, as the associa¬
tion of the University’s name invites the assumption that at least some
important share of the diplomate’s knowledge is the fruit of a school of
thought with traditions of its own. Should a diploma in psychological

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BY C. HUBERT BOND, D.SC.

medicine be ultimately obtainable at all our Universities, and especially
should their intramural arrangements permit of the development of a
school of psychiatry at each, perhaps this view will prevail.

(5) Another point upon which more precise information would be
helpful is the matter of fees for instructional courses. The fee for each
course should be stated, and it would be advantageous were a composition
fee quoted for the courses of Part I of the examination, another for
Part II, and a third for both Parts.

(6) The examination for each of the five diplomas is divided into
two parts, and the subjects, with some variation, fall under the following
eight heads : (a) Development and anatomy of the nervous system ;
( 6 ) physiology, histology and chemistry of the nervous system ; (c)
pathology of the brain and nervous system, with post-mortem room and
laboratory technique; ( d ) bacteriology, in only two of the diplomas, and,
as respects one of them, limited to its relation to mental diseases—these
four heads are invariably comprised in Part I of the examination, as is
the next head in the case of one diploma; (<r) psychology, systematic
and experimental; (/) neurology; ( g ) psychiatry; and (A) clinical
psychiatry. It is suggested that in each of the diplomas Part II should
be reserved for the strictly professional subjects and that it should be
required to be passed as a whole; but that permission should be accorded
for candidates to present themselves in the subjects of Part I separately,
and also to be exempted from any subject of Part I in which they have
previously passed an examination of not less standard and scope. For
example, the latter concession might apply, as regards the anatomy and
physiology of the nervous system, to those who have passed the Primary
Examination for the Fellowship of the College of Surgeons of England ;
as regards bacteriology in its relation to mental diseases (where included),
to those who possess a degree or diploma in public health ; and as
regards psychology—which, under the suggestion as to the scope
of Part II, and probably more logically, would fall into Part I—to
graduates in arts or science for whose degree psychology has formed a
subject. It is further suggested as regards Part II that, besides psychiatry
and neurology, the time has come when the importance of knowledge
of psychopathology, the psychoneuroses and psychotherapy demands
the inclusion of these matters in this curriculum and examination—a
view supported by a commentary by Prof. T. H. Pear, of Manchester,
lately made to teachers in psychiatry, and by my former colleague Dr.
Bernard Hart in a communication^) in connection with an inquiry into
“The Training of the Student of Medicine ” carried out by the Edinburgh
Pathological Club. The adoption of this suggestion should carry with it
recognition of clinical experience of the psychoneuroses, either as an
extra or in lieu of, say, three months of the time prescribed for clinical
instruction in psychiatry where that period extends to not less than a

LXVI, 2

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18 THE NEED FOR SCHOOLS OF PSYCHIATRY, [Jan.,

year; such recognition has already been sanctioned at one of the
Universities. Further, not, however, as an addition, but in order to
emphasise the principle that specialism should only be encouraged when
based upon a competent general knowledge, this opportunity is taken
to suggest that “ The relation of psychiatry to general and preventive
medicine ” should be specified as a sub-head in Part II.

(7) Lastly, the diplomas and instructional courses should, as seems
so far the case, be as freely accessible to medical women as to men.
Mention is only made of the point by way of emphasising the useful
sphere open to women as asylum physicians.

It would, however, be a mistake to dwell too insistently upon the
possession of this or that diploma; it is but a hall-mark. The really
important result to be attained is that, based upon a previous thoroughly
sound knowledge of general medicine, a prescribed course of instruction
shall have been followed, and that there shall have been acquisition of
knowledge not merely of facts memorised, but of principles which not
only render the holder at once more efficient, but which, by the force of
his awakened interest, result in his becoming a true student of his
special branch of medicine throughout his working years.

Our goal, therefore, should by no means be limited to repetitions of
courses of instruction leading to a diploma at certain or preferably at
each of the Universities. Rather should we urge that the importance
of the whole subject of mental health justifies and calls for, not merely
a colleague relationship between the several teachers in our diplomate’s
curriculum—some of whom may possibly belong to other Faculties in
the University than that of medicine—but a partnership so outwardly
and visibly manifest as to deserve the name of School of Psychiatry;
and differences in tradition between such schools will be all to the
good.

(1) To Secure Instructional Courses and Opportunities for Continuation

Studies.

For such local consolidations of teaching activities the foundation
may be said to exist already at practically every University. For
example, courses of anatomy and physiology on a standard for advanced
students are given yearly, and a few weeks of each of these two courses
are devoted to the nervous system. It may be that at present the
weeks covered by the anatomy of the nervous system do not coincide
with those given to the physiology of that system ; but would the
rearrangement necessary to make them do so, and other similar adjust¬
ments to enable the subjects of Part I of the Diploma (so far as they
may be said to comprise the institutes of psychiatry) to be taught

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BY C. HUBERT BOND, D.SC.

simultaneously, present serious difficulty or dislocate work in a manner
prejudicial to those taking the full courses? Inquiry at least might be
made, and, if the answer is in the negative, the road to the assistance
we want seems smooth—still more so when the number of teachers and
laboratory facilities are on a considerable scale. As regards Part II,
adjustments are probably not necessary; but lecturers in sufficient
number may not at once be available, especially if they are to be
properly remunerated.

But to overcome admitted difficulties, and to induce a correlation
of work on the part of a body of teachers whose duties and interests are
much wider than merely towards the sphere in which our interest lies,
demand reciprocity as expressed by a clear call for such assistance—
a call which, if limited to ambition to obtain a diploma, will be too
faint to produce an effective echo. In other words, a correlation
and consolidation of work worth the name of school of psychiatry
(or neuro-psychiatry) connotes a bilateral contract that supply and
demand shall correspond, and an* avowed intention to advance both
these complements.

(2) To Develop Schools of Psychiatry.

In the face of the knowledge of facts acquired in recent years as to
psychology in the abstract and mental health in the concrete, it is
inconceivable that a University will willingly be without such an organic
unit as is here meant by a school of psychiatry. Should we therefore not
see to it that support is not lacking from the periphery? Is it too much
to ask that those who, by the responsibility they assume, profess expert
knowledge—be it in psychology, neurology or psychiatry (severally or
as a triad), and whether their responsibility extends to the abnormal
or to the maintenance of a watch on the mental development of normal
children ( 8 ), or whether they act as aids in the capacity of social service
workers—is it too much to expect them, collectively and individually,
to give active assistance in the development of such schools, and to
maintain a close working association with them ? It is fatally easy for
our professional work to slip into a groove which, followed, ends in
mental fog; and to dispel which, or prevent its rising, is there anything
more potent than a breath of the atmosphere of a progressively animated
University ?

Inconvenient distances and perhaps other difficulties at once present
themselves to our minds; but, if the situations of the institutions from
whose medical staffs this Association mainly recruits its members are
examined in relation to their proximity to the nearest University, it is
surprising, in the face of all that has at times been said as to the isolation
of their positions, to find how comparatively few there are, at least of those

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THE NEED FOR SCHOOLS OF PSYCHIATRY, [Jan.,

in England and Wales, which are not sufficiently near a University to
enable a reasonable number of hours—be they at a clinic, in laboratories,
in libraries or at discussions—to be put in and the journey to and fro
to be made on one day. Time so taken should count for grace, not
as neglect of official duties, so long as in fact they are not thereby
neglected, and not as part of needful recreation.

To be effective, such attendance and visits must be regular and form
part of a recognised scheme between the institutions grouped round
the particular University, and they take for granted—which is what we
may be sure the Universities would like us to do—their active goodwill
and co-operation. But before birth can be given to such a scheme—
and as left with you to-day it is in very crude form—definite adherents
must be forthcoming, and it is because this Association is in the best
position, both to ascertain if a sufficient number of would-be adherents
exist and to put the scheme into better shape, that I have used this

opportunity( 9 ) to lay it tentatively before the meeting.

ADDENDUM.

Diplomas in Psychological Medicine.

Summary of Requirements of those now Existing.

Based upon suggestions made in 1908-9 by the Medico-Psychological Associa¬
tion—who still grant their own certificate in mental diseases which was established
in 1892, and has been taken by 370 medical practitioners—five of the Universities
in Great Britain have instituted and now grant a diploma in psychiatry or psycho¬
logical medicine, as indicated in the subjoined table.

Date of
institution.

University.

Designation of diploma.

1910

Manchester

Diploma in Psychological Medicine.

1911

Leeds

• n 11 11

1911

Edinburgh

„ Psychiatry.

1912

Cambridge

. ,, Psychological Medicine.

1912

Durham

,, Psychiatry.

While their regulations point to much similarity in their scope and examinations,
these five diplomas present several important differences, of which, and their simi¬
larities, the following is a summary :

(1) Age and medical standing. —No minimum age is prescribed by any of the
five Universities, and the diploma of each of them is open to all medical practitioners
whose names are on the medical register, except in the case of Leeds, whose diploma
is restricted to graduates in medicine (but not necessarily of Leeds) of one year’s
standing. Manchester and Cambridge require candidates to have attained a regis¬
trable qualification at least two years previously to their completing the examination
for the diploma, but both permit Part I of the two divisions, into which each of the
five Universities divide the examination, to be passed at any time after qualification.

(2) Duration of courses. —One academic year of three terms is ordained at
Manchester and Edinburgh; six months at Leeds; and, while no corresponding
period is specified at Cambridge and Durham, the latter University prescribes either
the length of each instruction course or the number of hours of work to be performed
(see (i) to (viii) below), and the former enjoins at least twelve months’ clinical
experience in an institution for the insane (see (vii) and (viii), and note (A) below).
At Durham, practitioners registered prior to the year 1911 are excused from
attendance on the courses of instruction specified for the diploma.

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2 I

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(3) Attendance at the University granting the Diploma. —At Manchester two
of the requisite three terms must be spent at that University ; at Leeds a six months'
course of systematic instruction on the normal and morbid anatomy and histology
of the brain must be pursued in the recognised laboratories of the University ; at
Edinburgh attendance at the University on five of the prescribed eight courses is
obligatory; none is insisted upon at either Durham or Cambridge.

(4) Curriculum and examinations. —These comprise, in varying extent as
indicated, the following eight heads :

(i) Development and anatomy of the nervous system. —Manchester’s require¬
ments are set out in the next paragraph; and for those of Leeds and Cambridge
see notes (n) and ( 4 ) below. By Edinburgh and Durham ten meetings of two
hours each are specified; the latter University indicates the standard as an
advanced one.

(ii) Physiology, histology and chemistry of the nervous system. —At Manchester
heads (i) and (ii) are grouped together and an approved course is required. The
requirements at Leeds and Cambridge are indicated in notes (a) and ( b ) below.
Thirty meetings, each of two hours’ duration, are allotted by both Edinburgh and
Durham.

(iii) Pathology of the brain and nervous system, with post-mortem room and
laboratory technique. —At Manchester an approved course is required and for
Leeds and Cambridge see notes (a) and ( b ) below. Edinburgh and Durham both
specify twenty meetings of two hours each.

(iv) Bacteriology. —Edinburgh limits the scope to its relation to mental diseases
in a three months’ laboratorycour.se of two or three hours daily. Durham requires
the same course of instruction as for its degree of Bachelor in Hygiene. The
other three Universities do not demand work in bacteriology further and subsequent
to that included in the general medical curriculum ; but as to Cambridge, see the
latter part of note ( 4 ).

(v) Psychology, systematic and experimental. —Instruction at an approved
course is required by Manchester and Leeds, qualified in the case of the latter by
especial reference to the symptomatology of mental diseases. A course of from
twenty-five to thirty hours is required by Edinburgh and Durham. At Cambridge
—and see note ( 4 )—this subject is included in Part I of the examination, whereas
at each of the other four Universities it is reserved for Part II.

(vi) Neurology. —A course of ten clinical demonstrations is prescribed by both
Durham and Edinburgh, the former limiting them to the rarer forms of nervous
disease and the latter regarding them as supplementary to the ordinary M.B.
course; and a course of clinical neurology is required by Manchester. Thus at
each of these three Universities emphasis is laid upon the clinical aspect of this
subject, but at Cambridge, while the duration of the course is not specified—see note
( 4 )—a syllabus is laid down and there is a written as well as clinical and oral
examination in neurology. In the Leeds curriculum there is no specific reference
to neurology, reliance apparently being placed upon the courses under heads (i),
(ii) and (iii).

(vii) and (viii) : Psychiatry and clinical psychiatry. —A six months' course of
instruction in psychiatry (systematic, clinical, medico-legal and asylum admini¬
stration) is prescribed by Manchester, but this course is apparently excused in the
case of those who have acted as resident medical officer in an asylum for one year
or for the two separate periods of six months. Leeds requires a six months' course
in clinical psychiatry, asylum administration and the medico-legal aspects of
insanity, and residence in an asylum as clinical clerk or assistant medical officer for
six months, but the instructional course is excused where the candidate has been
an assistant medical officer for two years in an asylum with at least 500 beds.
Both Edinburgh and Durham require lectures in a course of ten hours supple¬
mentary to the course required for the M.B. degree, and both require instruction
in clinical psychiatry either in a course of six months given at a recognised
institution or in a course of three months, coupled with the holding of a resident
appointment for three months—both alternatives being subject to modification if
residence has extended to six months. Cambridge requires twelve months’ clinical
experience in a recognised institution, for which purpose special neurological
hospitals of over 40 beds, under either the War Office or Ministry of Pensions,
have recently been added to the list of places so recognised.

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2 2 THE NEED FOR SCHOOLS OF PSYCHIATRY. [Jan.,

Note (a).—The Leeds regulations do not lay down the length and scope of the
several courses required with as much particularity as generally elsewhere ; but
there is a governing regulation prescribing, for all the subjects of examination for
the diploma, attendance on approved courses of instruction during six months at
least after graduation; it may also be noted that its regulations with respect to
heads (i), (ii) and (iii) refer specifically to the brain and not to the nervous system
in general.

Note (6).—The Cambridge regulations make no specific reference to attendance
at instructional courses, but wide powers to determine generally matters connected
with the examination are left to a managing committee nominated by the State-
Medicine Syndicate; and while schedules of the matters included under heads (i),

(ii) , (v) and (vi) are supplied, it is made clear that they are merely for guidance
and not to limit the scope of the examination, which is intended to test the
candidates’ theoretical and practical knowledge of every branch of psychological
medicine.

(5) Examinations. —As already indicated, each of the five Universities groups
the subjects it requires into two parts; each part forms one examination, and
Part I, except at Cambridge, must be passed prior to or at appearance for Part II.
Except at Cambridge, the subjects numbered (i), (ii), (iii) and, where required,
(iv) are comprised in Part 1 and (v), (vi), (vii) and (viii) in Part II. At Cam¬
bridge Part I comprises subjects (i), (ii) and (v), while Part II includes (vi), with

(iii) , (vii) and (viii).

(6) Fees for instruction. —It is not easy to ascertain them from the regulations
as respects Manchester, Leeds and Cambridge. A composition fee of 25 guineas
is payable at Durham and the total of the fees at Edinburgh amounts to about
18 guineas.

(7) Examination fees. —These amount to 10 guineas at Manchester, Edinburgh
and Durham, 5 guineas at Leeds and 12 guineas at Cambridge.

In addition to these five diplomas a diploma in mental diseases, open to
graduates in medicine, was instituted by the Royal University of Ireland in 1895 and
is still maintained by the National University. Particulars as to this diploma
will be found in the calendar for 1919 at pp. 120 and 264.

Several of the Universities in the United Kingdom recognise mental diseases
as a subject in which a candidate may specialise for the degree of doctor in
medicine. Notably psychological medicine is one of the departments in which
the degree of M.D. may be taken at the University of London. Mental disease
is also one of the special departments in which a candidate may exercise his choice
as to one of the three cases, upon which he must submit a written report and
commentary at the clinical part of the examination for the M.D. degree at the
four Scottish universities.

None of the colleges of physicians grants a diploma in psychological medicine,
notwithstanding that they all do so (conjointly with the corresponding college of
surgeons) in public health, and that one of them does so in tropical medicine.
The Royal College of Physicians of London, however, holds for its members (but
not for its licentiates) an examination in psychological medicine and permits the
fact of this having been passed to be endorsed on the membership diploma. At
the Royal College of Physicians of Edinburgh candidates for the membership are
required to pass an examination (1) on the principles and practice of medicine,
including therapeutics, and (2) on one of nine subjects—among which is psycho¬
logical medicine—to be selected by the candidate, in which a high standard of
proficiency is expected. At the Royal Faculty of Physicians and Surgeons
of Glasgow the examination for the Fellowship comprises either medicine or
surgery and one, at the option of the candidate, of some thirteen subjects
or branches of surgery and medicine, among which is psychological medicine.
It may be of service to mention here that in the case of candidates who have
served in the recent war at home or abroad, it is possible during the ensuing five
years to secure the privilege of being examined for this Fellowship solely in psycho¬
logical medicine. At the Royal College of Physicians of Ireland candidates for the
membership are required to pass a general examination in medicine and pathology
and a special examination in one of three groups or in a group or subdivision of
medicine, which shall be judged to be equal in value to one of the specified
groups; and it is understood that the College, upon two months’ notice, are

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1920.] CASES WITH ENDOCRINE CONSIDERATIONS. 23

willing to consider the value of subjects submitted by a candidate who wishes to
specialise in psychological medicine.

While care has been taken to make this summary accurate, intending candidates
should, of course, consult the official regulations.

(’) See Lancet, April 6th, 1912^.934; ibid., June 21st, 1919, p. 1092; ibid.,
August 2nd, 1919.—( 2 ) Journal of Mental Science, vol. lxi, 1915, p. I.— (*) Ibid.,
vol. liv, 1908, p. 550.—(*) Ibid., vol. liv, 1908, pp. 791-3.—( 6 ) Ibid., vol. lv, 1909,
p. 757, and vol. lvi, 1910, p. 374.—( 6 ) Ibid., vol. Ivi, 1910, p. 373.—(') Edinburgh
Medical Journal, October, 1918.—( 8 ) See Lancet, April 27th, 1912, p. 1017; and
December 20th, 1919, p. 1167.—(®) Quarterly Meeting of the Association, Novem¬
ber 25th, 1919.

Some Mental Cases with Endocrine Considerations. By Guy P. U.
Prior, M.R.C.S., E.R.C.P., Medical Superintendent, Mental
Hospital, Rydalmere; with Reports on Microscopical Findings by
S. Evan Jones, M.B., Medical Officer, Mental Hospital, Callan
Park, New South Wales.

It is well known that with the grosser lesions of many of the ductless
glands there are profound alterations in the subject’s mental powers.
There are doubtless many less pronounced mental alterations due to
slighter lesions of these glands which are for the most part unrecog¬
nised—in fact difference in character and disposition in different indi¬
viduals and in the same individual at different times may be due to the
variation in the balance of the internal secretions.

Those alterations due to lessened action of a gland have been brought
about experimentally by removing the gland in question, with con¬
stantly recurring results.

The mental changes due to over-secretion of a gland are not so well
understood, and the effect produced by prenatal or congenital gland
disease upon the cerebral development has hardly been studied.
Congenital thyroid disease in the form of myxoedema and cretinism
and the results of treatment with thyroid are known, but the effects of
early or congenital failure of the other glands are not, and it is possible
that the changes in the central nervous system caused by these may be
as far-reaching as those in thyroid failure. It is likely that early
changes in gland tissue may be a potent cause of imbecility. Many
an imbecile bears unmistakable signs of glandular dystrophy. An
Editorial article in Endocrinology refers to an unpublished paper, which
states that of t,ooo defective children 17 per cent, were recognised
as of endocrine origin (1). The same article also states that the Binet-
Simon age of defective children has been advanced many years after a
few months of treatment with thyroid or pituitary. It is possible that
there is a large class of ill-defined cases of want of endocrine balance
seriously affecting both physical and mental development, which, if

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capable of early diagnosis and treatment, might enable some imbeciles
to attain a fair, if not average, degree of intelligence.

The cases i, 2, 3, 4, 5, 8, 14, 15, 17, 18, 23, 26, 27, 28 and 29 of our
series are congenital or of early development, and show evidence of
glandular irregularity.

Their condition in the present state of knowledge cannot be diagnosed
until there is structural deformity or want of mental development. Did
it lend itself to an earlier diagnosis their future outlook might be very
different.

The glandular influence on physical development and structural
change is better understood than is its influence on the mental develop¬
ment. The large formation, with its increase in bone growth of
acromegala and its opposite condition of dystrophia adiposa genitalis,
is well known, as also is the difference in the conformation of a
myxoedemic and a case of Graves’s disease. The changes in an animal
after castration, both in character and structure, and the eunuchoid
condition due to lack of secretion of the interstitial testicular cells, and
the changes in the secondary sex characters and the early sexual
development due to lesions of the suprarenal or pineal, present no
difficulty in recognition.

Feeding of Tadpoles and Guinea-pigs with Glandular

Extracts.

The tadpoles were taken from the pond when about two weeks old, and, as
near as possible, were selected of the same size. They were fed every morning with
a tabloid of the respective glands. They had no other food except bread-crumbs
and water-weed, but this was a mistake, as it would have been better to have given
them some animal food, as the controls received none, while the others did in the
gland. Thfe fact that the controls did not develop detracts from the value of the
observations, but the results obtained from the gland-fed tadpoles, compared with
each other, may be of some interest. The tadpoles were taken on October 27th
and put into separate bowls, and fed upon thyroid, parathyroid, thymus, didymin,
suprarenal, anterior pituitary, and another lot received no gland.

Those fed upon thyroid were all dead by November 19th. They were extremely
small, in fact no bigger than on October 27th ; they had four legs, and their tails
were nearly absorbed before dying. Some day or two before they died they would
suffer from syncopal attacks, would swim very quickly round the bowl, suddenly
turn on their backs, and drop to the bottom of the water, where they would lie as
if dead for ten minutes or more, and then get up and repeat the performance.

Those fed on thymus were, on November 15th, four times as large as the
controls; one had hind legs, another none; they were pale in colour and trans¬
lucent. By December 12th three had died. One had changed into a frog and
escaped. The others were large tadpoles, with small hindlegs; their bodies were of
more triangular shape than those fed with other glands, and they were more
translucent. By January 12th three were still tadpoles with hind legs and no fore¬
legs. One had a haemorrhage into his abdominal cavity, and was so transparent
that his heart could be seen beating and his viscera could be distinguished. That
thyroid feeding hastened metamorphosis and retarded growth of tadpoles, and
that thymus has the reverse action, causing the tadpoles to become of abnormal
size, was pointed out by Gudernatsch (2).

Of the others, those fed with parathyroid remained very small, and by January

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Fig. 1.

Fig. 2.

1. Control. 2. Parathyroid. 3. Thymus. 4. Didvmin.
5. Suprarenal. 6. Anterior pituitary.

To illustrate paper by Mr. Guv P. U. Prior.

Aii/ahf S' Sen S' li t 1 1 Xvivumn. I.tii .

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12th there were still several tadpoles not much bigger than at the commencement.
One had become a small frog by December 18th, and died two days after. By
December 30th two more had become frogs, and were also very small, dying
almost immediately.

Those receiving didymin were the most inconsistent. Some had become frogs
by December 12th, and quickly escaped. By January 12th one was very large,
pale and translucent, and of the shape of those that had received thymus, and
others were darkly pigmented and with hind legs.

The suprarenal tadpoles were more forward with their legs than any of the
others except the thyroid, and were also darker in colour. They were of more
slender build and their limbs longer and finer than the anterior pituitary ones.

The anterior pituitary tadpoles showed the most definite changes, though these
were not uniform. On November 19th it was noted that they were much larger
than any of the others. On November 25th two were of extreme size, with very
long, thick tails, no legs, and their companions had small, thick legs and abnormally
large bodies. On December 18th five survived—three frogs and two tadpoles; these
latter were the largest and heaviest of the collection. The frogs were also larger
than the others, the legs being shorter and thicker and the skin markings more
distinct.

By the end of the time of our observations none of the controls had changed
into frogs, though some had hind legs. They were smaller and more backward
than any except the parathyroid, of which they were about three times the size.
The lack of animal food in their case may have kept them back. On December
18th the largest tadpole in each bowl was weighed, with the following results:
Control, 1,220 mg.; thymus, 3,330 mg.; parathyroid, 900 mg.; didymin, 2,320 mg.;
suprarenal, 4,106 mg.; anterior pituitary, 5,520 mg. Fig. 1, taken in January,
shows the relative size of the tadpoles at this time. Fig. 2, taken at the same
time, shows the most advancedly developed. It will be seen how much larger
the anterior pituitary tadpoles are than the others and the undeveloped condition
of those being fed with parathyroid. It is, of course, impossible to draw any
definite conclusions from these observations, but they bear out the observations
already made upon thyroid and thymus feeding. It also seems that parathyroid
delays both metamorphosis and growth and that suprarenal stimulates both, but
without the far departure from normal caused by anterior pituitary, which stimu¬
lates growth and causes bone changes.

In reference to a paper by McCord and Allen on feeding tadpoles with pineal
gland they found a marked reaction of the pigment-cells, so that in thirty minutes
those of the pineal-fed tadpoles were much larger than the controls. (3)

We have also made feeding observations upon guinea-pigs. The does were fed
with the gland the day their young were born, the mothers being removed a week
later and the young continued to be fed with the gland for from five to six months,
their weight being taken weekly and the time of reproduction noted. Where
several guinea-pigs in the same pen have grown at about the same rate only one
is recorded ; where there has been much difference two are shown on the chart.
The controls steadily increased throughout. Those fed on thyroid lost weight
towards the end and never grew to the same degree as the controls, and were all
the time of thin, sickly appearance. One, when a month old, fractured a leg from
unknown cause, but disturbance of his calcium metabolism may have had some¬
thing to do with this. The parathyroids, for a time, remained stationary and at
one time lost weight, but at the finish were as heavy as the controls. Those fed
on thymus, whole pituitary, anterior pituitary and suprarenal developed about
normally except that the last two did not reach to within two or three ounces of
the controls. The pigs taking didymin were much inhibited and those taking
varium were inhibited to a lesser degree. In these two pens no buck was born ;
the effect of the feeding applies only to does. A buck was put in with them when
they were a few weeks old, but as they were not fed from the first with the gland
a record of them was not kept. The pineal pigs grew very slowly for the first
five weeks, but by the twenty-second week were well up to the normal.

At the end of our observations the young guinea-pigs varied in age from
22 weeks to 28 weeks. They normally reproduce at from five to six months. (4)
Our control was 23 weeks old and was in young. The parathyroid had one
young when 22 weeks old, the whole pituitary one at 24 weeks, and the anterior

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pituitary one when 20 -weeks old. The pineal doe at 25 weeks was heavy in
young. The pineal pigs had long, straight and silky hair such as we do not
remember seeing before in a guinea-pig, but we cannot say that this was the
result of feeding and not of breeding. In the thyroid at 22 weeks, thymus at
25 weeks, suprarenal at 23 weeks, didymin at 25 weeks and varium at 27 weeks
there was no pregnancy. It is stated that animals fed upon extracts of the glands
strike a fresh balance of glandular activity after a time and no great change is
brought about by such feeding. The results are also said to differ with the age
at which the animal is commenced to be fed.

The thyroid is the gland about which most is known as to its
relationship to the mind. A myxoedemic patient is depressed, dull,
slow in thought and action, with diminished reflexes, often with
hallucinations of hearing due to the swelling of the aural mucosa or
of central origin, and not rarely finds her way into a mental hospital,
where she is generally found to be a melancholic and irritable patient,
indifferent to her surroundings, idle and without interests, with a more
or less marked degree of dementia. Case 16, referred to in detail
later, was such a one.

In cases of hyperthyroidism there is the reverse mental picture.
She is often of cantankerous disposition and ever ready to take offence,
but she thinks and talks quickly, her movements are rapid, and her
energy abundant. Should she become insane, she generally suffers
from acute or subacute mania unless the condition passes from
hyper- to hypothyroidism, when the condition becomes one of melan¬
cholia.

Of the congenital mental conditions accompanying diseased states
of the thyroid we have cretinism—sporadic and endemic—Mongolism
and infantile myxcedema. With these there may be all degrees of weak-
mindedness—from the most extreme idiocy to a high-grade imbecile.
Mongolism is probably not entirely an athyroid condition and does not
improve to any extent with thyroid treatment, though Case 17 livened
up after receiving thyroid in small doses for some months, while her
hair-growth also improved somewhat.

Cretins and infantile myxcedemics make great improvement with
thyroid therapy. McCarrison records the case of a cretin, set. 9,
who could neither walk nor talk, but who, after treatment with thyroid,
was able to walk, and learned to say a few words. (5) As a rule the
earlier the treatment is begun the better the result.

The mental symptoms of an adult myxcedemic are greatly improved,
if not cured, by taking thyroid. Hertoghe says that nerve-cells are not
destroyed in myxcedematous infiltration, but become infiltrated and
' depressed, and that transmission of impulses, though delayed, is not
abolished. (6)

The thymus gland has some influence upon mentality. Sajous
states, “ Removal of the thymus in dogs is followed by clear evidences

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BY GUY P. U. PRIOR, M.R.C.S.

2 7

of idiocy (Morel). The thymus was present in all of 6i autopsies
performed by Katy on mentally normal children. In 28 mentally weak
children examined by Bourneville it was absent. In another series of
408 autopsies on non-myxoedematous children of from one to five years
of age the thymus was present in only 104 cases.” Sajous attributes
this to the presence of thymus being necessary for the proper carrying
out of the phosphorus metabolism, which is important for the develop¬
ment and maintenance in health of nerve-tissue. (7)

In our series of 46 post-mortem examinations from which the glands
had been taken for examination, 25 cases had a definite thymus gland.
Twenty-three of these were confirmed by microscopic examination, and
6 were not sectioned. Among these 46 cases were 32 epileptics, 22 of
these latter having the thymus present, of which 18 were sectioned and
examined with the microscope. The largest glands were found among
the epileptics. Eight epileptics were cases of sudden death, 7 being
under our care, while 1 of great interest was from a neighbouring
hospital, and at whose autopsy we were allowed to be present. All
these cases had enlarged thymuses. Two may be described as being as
large as the palm of the hand; of the others, one weighed 3^ oz.,
another 2 oz., and a third 1$ oz. The youngest of these 8 patieuts was
20 years and the oldest 53 years. Two of them were found dead
at night, having been seen previously to within half-an-hour, and both
having been in their usual health the day before. One was Case 5, to
be described later under the apituitary cases, where a description of his
glands will be found. Case 31, the other patient who was found dead,
was of eunuchoid type, an imbecile and a sexual pervert, whose epilepsy
had commenced at 15 years of age, and who was 22 years at the time
of his death. He had a very large thymus, reported to be a persistent
infantile one. The suprarenal, both cortex and medulla, showed
degenerative changes.

Case 32 was aet. 46. His epilepsy had commenced ten years
previously. He died immediately after taking a fit—the third within
eight hours. An attendant was standing beside him at the time. A
post-mortem examination was made, and the heart, lungs and kidneys
were found normal. There was a considerable amount of thymus
tissue, reported to be very vascular and of a regenerative type. The
suprarenals showed degenerative changes, both of cortex and medulla.
The thyroid showed vesicles small and irregular, the lining epithelium
cubical and actively proliferating. The intermedial tissue was increased
and the blood-vessels congested. The pituitary was in a condition of
over-activity. There was a small and normal parathyroid.

Case 33 was a girl, ret. 25, an epileptic of ten years’ duration. She
did not have an epileptic attack on the day of her death, but after
going to bed became very restless, wandering about the dormitory. On

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being put back to bed by the nurse, for the third time, without any
resistance or struggling, she collapsed and died. An autopsy was
made nineteen hours after death. There was slight active tuberculosis
of both lungs. The heart was soft and flabby; the aorta was small,
admitting only one finger. There was thymus tissue present: it was
reported to be a retrogressive infantile one, and to contain numerous
Hassall’s corpuscles and also particles of lime. The ovaries were
fibrotic, and the vessels in process of obliteration. The spleen con¬
tained numerous small haemorrhages. The pancreatic cells were
shrunken and very few islets were to be seen. The suprarenals were
reported to be normal.

Cases 34, 35 and 36 all died shortly after taking a fit, and were
under different observations at the time of their death. Case 34 was a
man, aet. 20 ; was heard at night by an attendant to be in a fit, and was
in the convulsion when the attendant went to him, but died immediately
the convulsion had ceased. A post-mortem was made six hours after
death and there was venous engorgement of all organs. The thymus
was much enlarged. In this case also the aorta would only admit one
finger, otherwise the heart was normal. The report on his glands
stated that the thymus was of persistent infantile type, that the testes
showed interstitial fibrosis and diminished activity, that the thyroid
was quiescent, there was advanced vacuolation of the suprarenals, and
that the section of the pituitary showed an effusion of serum into
the pars intermedia.

Fig. 3 shows a thymus of infantile type. Note the dilated capillaries
and large Hassall’s corpuscles.

Fig. 4 shows a thymus of a regenerative type showing small masses of
fine thymic tissue containing Hassall’s corpuscles scattered through the
fatty areolar tissue.

Case 35 was aet. 31 and had suffered from epilepsy since he was
twelve years of age. He had had five fits the night previous to his
death, and three on the afternoon on which he died, dying immediately
after the last. Before this he was conscious and fairly well. An
autopsy was held eighteen hours after he died. The heart was dilated, the
muscle being flabby; the aorta would admit two fingers through the
orifice from above. The thymus weighed 3^ oz., the thyroid 1 oz. and
the spleen 6 oz. From the microscopical examination of the glands it
was stated that the thymus was a persistent infantile one, that the
testicles were normal, also the pituitary and spleen. The thyroid
was of increased, and the pancreas of diminished, activity. Of the
suprarenals, it was stated that the cortex showed advanced degeneration
and that the medulla stained normally, but was intensely congested.

Case 36 was a male patient, set. 53 years, 6 ft. 3^ in. in height, and
deficient in secondary sex characters. He had suffered from epilepsy

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for many years. He had eight fits within half-an-hour, and did not
recover consciousness between them. He was being given a soap-and-
water enema when he collapsed and died, before the enema had acted.
A post mortem examination was made twenty hours after death. The
body was very fat and the skull very thin. The brain weighed 48 oz.,
and the ventricles were moderately dilated. The heart weighed 14£ oz.
the aorta being normal. The spleen weighed 6| oz., the thyroid 2 oz.,
and the thymus 2 oz. The two suprarenals together weighed 1^ oz.
The pituitary was large, the sella turcica being broad and deep. The
pineal gland was noted as being large. This is one of the cases in
which the thymus was not sectioned. The thyroid was over-active,
the pituitary and testicles normal, and there was fatty infiltration of the
liver.

Case 37 died four hours after being given an injection of typhoid
vaccine. He was set. 30 and an epileptic since early childhood. A few
minutes after receiving the vaccine he had a rigor and a little later his
temperature rose to 105° F., and he died within four hours with signs
of acute pulmonary congestion. He had not at this time had any fit.
The post-mortem examination was made twenty-three hours after death.
The brain was found slightly congested, the sella turcica was small and
shallow, the posterior processes were bent forward, and the pituitary
was smaller than normal. The heart was dilated, the muscle flabby,
the aorta small, admitting two fingers. The lungs were acutely con¬
gested. The thyroid was large, the thymus weighed i| oz., the pancreas
was acutely congested, and the liver and spleen were also congested.
The following is the report of the microscopical examination of his
glands : The thymus of persistent infantile type. The suprarenals—
the cortex exhibits well-marked vacuolation. The testes normal. The
pancreas showed extremely acute congestion—the alveoli and islets
were disorganised. The brain showed nothing abnormal except extra¬
vasation of blood-cells from small capillaries. The heart-muscle
appeared normal and the kidneys intensely congested. This man had
received typhoid vaccine twice previously, at two-yearly intervals. He
had been trephined, operated upon for appendicitis, also received “ 606 ’’
intravenously three times.

Taguichi records the case of a healthy man, set. 57, who died within
an hour of receiving 1 c.c. of typhoid vaccine. On post-mortem exami¬
nation evidence of thymus lymphaticus was found (8). All our 7 patients
above described, together with others who have evidence of enlarge¬
ment of the thymus, have been given typhoid vaccine without ill-effects.
Case 36 had many opportunities of dying suddenly, in ways common
in status lymphaticus , and why these causes should act at one time and
not another, it is not possible to say.

The ductless glands in epileptics show a far departure from the

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normal. Including the 8 cases of sudden death, we have made post¬
mortem examinations and sections of some or all of the glands upon 32
epileptics, of which 20 were male patients and 12 female.

Of the male patients, 15 had enlarged thymuses, and in 5 the gland
was not present.

The suprarenals showed degenerative changes in 15 cases, were found
to be normal in 3, and in 2 they were not examined. The changes
in the suprarenals were mostly found and more marked in the cortex.
The cells of the cortex failed to stain, the nuclei stood out well, but the
cytoplasm was coarsely granular or represented by a fine network
enclosing clear spaces. In 4 cases the degenerative changes were well
marked in the medulla as well as in the cortex.

The testes from 4 patients were not examined; from 12 they were
found to be normal, and from 4 there was a deficiency in the interstitial
cells, one of these being Case 5—an apituitary one.

The pituitary showed no constant change in 11 cases ; it was either
normal or of slightly increased activity. In 5 cases it was not examined,
in 3 it was stated to be of diminished activity, and in 1 case, dying
suddenly, there was a serous effusion into the pars intermedia.

The thyroids were mostly of the two types, 6 being taken as being
quiescent and 7 as of over-activity. These we equally divided, there
being 7 of each in our series; in 4 cases the thyroid was normal, and
twice it was not examined.

The pineal was only examined twice. In one case it showed degenera¬
tive changes and in the other it was normal.

The liver was examined from 10 patients. Once it was found normal;
all the others showed signs of fatty degeneration or fatty infiltration.

The pancreas was reported upon from 8 patients. In 3 it was normal;
in the other 5 the islets of Langerhans were few in number and showed
degenerative changes.

The spleen was examined from 7 patients. From 1 case it w r as
reported normal, in 1 there were small haemorrhages, in 1 waxy degene¬
ration ; the rest showed fibrotic changes.

In the 12 female cases an enlarged thymus was found in 7 cases, the
condition being confirmed by the microscope in 6, in 1 case not being
sectioned. The gland was absent in 5 cases.

Of the ovaries, in 1 case these glands could not be found at the
post-mortem and were presumedly congenitally absent, in 3 cases they
were not examined, and in 8 cases the fibrous tissue was much increased
and the organs were shrunken and atrophic. In 3 instances small
Graafian follicles were seen.

The thyroid in 4 of the 12 cases was not sectioned; in 2 it was stated
to be normal, in 5 showing signs of over-activity, and in 1 case of under¬
activity.

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1920.] BY GUY P. U. PRIOR, M.R.C.S. 3 I

The pituitary was normal in 9 of the series, said to be of minus
activity in 1 case, and was not examined in two.

The suprarenals were normal in 5 cases, showed degenerative changes
in 6, and were not examined in one case.

The pancreas from 6 cases was examined. In 2 it was normal, and
in 4 the same degenerative changes were found as described in the male
cases.

The spleen from 4 patients was examined, 1 being normal; 2 showed
fibrotic changes and 1 was the subject of waxy degeneration.

The liver was examined from 9 patients. Once it was found normal;
the other 8 had fatty degeneration.

What strikes one as most worthy of note in these results is the large
percentage of cases in which the thymus is found to persist, and the
great number of times in which there is found degenerative changes
in the suprarenal cortex. That the liver, spleen and pancreas are
seldom reported to be normal is suggestive, but the number of times
these organs have been examined is not sufficient to say that changes
are constant. The fibrotic and atrophied ovary appear to be almost
invariably present, and the fact, as we have shown, that the menstrual
function is most irregular in epileptics (9) may depend upon this.
A corresponding change is not found to the same persistency in the
male sex gland.

Kajima describes similar ovarian changes as we have found in
epileptics in two cases of dementia praecox, but he found no testicular
changes.(10) Writing on the Abderhalden reaction, Orton says that
the majority of dementia praecox cases react against brain or sex gland,
or the two combined, showing a dysfunction of this gland.(11)
Dr. Kate Hogg, in an unpublished paper written ten or twelve years ago,
claims to have found changes in the uterus or ovaries in 21 out of 30
cases of dementia praecox examined. She came to this conclusion
from pelvic examinations made under an anaesthetic. She describes
the ovaries as being sometimes atrophic, sometimes subject to fibroid
degeneration, and sometimes as hypertrophied with loss of function.
She concludes the paper by saying, “ A condition exists which indicates
the unfitness of the organism to reproduce its like, which is the final
phase of degeneration." It would appear from the condition of the
epileptics’ ovaries that also in them Nature is endeavouring to eliminate
the unfit.

Over-activity of the thymus has been described as causing eunuchoid¬
like growth, i.e., tall individuals with long bodies and long limbs, and
deficient in secondary sex characters. Bandlier(i2) and Sajous(7)
both speak of an infantilism as being due, among other causes, to a
persistent thymus. Among our post-mortem cases, in which we have
found a large and active thymus, have been men of 6 ft. or over as Cases

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31, 36 and 38, the first 2 being of eunuchoid appearance, others being
of all degrees of size and weight, including two dwarfs as cases

5 and 18.

There are, in the series, three other cases not epileptics in whom an
enlarged thymus was found. Unfortunately only one of the three
glands was sectioned, this being from Case 18, which is described
under the cases; her thymus was a persistent infantile one. Of the
remaining two, one was from an imbecile lad of 18 years, who died
from pulmonary tuberculosis. His thymus weighed 2 drachms, thyroid

6 drachms, spleen 6 ozs., heart 8 oz., with an aorta that would only
admit one finger. The other was from an old lady ret. 73, who died
from intestinal obstruction. Her adiposity was rather in excess, and
the hair on head and pubes very scanty. At the post-mortem a cyst of
the pituitary was found, the pineal and thyroid were small and some
thymus tissue was present.

Diminished suprarenal activity may be accompanied by mental
symptoms. Acephalic monsters are said to have no suprarenals. It is
stated in Osier and Macrae that “ hypoplasia of the suprarenals ”
has been noted in the hemicephaly and other failures of brain develop¬
ment. Czery reports absence of medulla in 5 cases of hydrocephalus,
and Hanseman 8 cases of anencephaly with atrophy. They described
the mental symptoms in Addison’s disease “ as a tendency to fatigue
from mental or physical exertion. Constant apathy associated with
depression, insomnia or an increased tendency to sleep. Yawning,
loss of memory, delirium, dizziness, tinnitus and headache.”(i3)
Falta says that in the later stages there may be delirium, convulsions
and coma.(14) An over-action of the suprarenals in either sex is
manifest, by an increase in male sex characteristics and in the female
with amenorrhoea in addition.

“ YViesel believes that the status thymico-Iymphaticus is equal, or
almost equal, to the chromaffin tissue in the pathogenesis of Addison’s
disease. He suggests that adrenal inadequacy prevents the involution
of the thymus, the lymphatic glands undergo hyperplasia, the vascular
and genital systems hypoplasia.”(i5) If this is so it explains the
common association in epileptics of over-active thymus glands and
under-active ovaries and degenerative suprarenals.

Extracts of ductless glands of late have been found of service in a
wide variety of diseases and disorders. It is an extremely old method of
treatment. Harrower mentions Egyptian writings of about 500 b.c. in
which orchitic substance is advocated for the treatment of impotence.(i6)
Probably the first reference to organotherapy is in the Apocrypha,
where Tobias is commanded by an angel to take the heart, liver and
gall from a fish. The heart and liver were to be changed into smoke
and used as an inhalation for the purpose of driving away evil spirits.

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BY GUY P. U. PRIOR, M.R.C.S.

The gall was useful to anoint one who suffered from “ whiteness of the
eyes.'X 1 7) This was written between 625 and 700 B.c., but it is our
purpose to limit our remarks upon the use of these glands to our own
experience, which has been mainly with epileptics and primary dements.
The glandular treatment of mental cases has its definite uses without
doubt, and it is certain that the scope of this usefulness will be greatly
extended with larger experience of their use. A patient may be not
far removed from idiocy, or apparently advanced in dementia, and may,
by appropriate administration of gland extracts, be rendered quite
unrecognisable from what he was, and who can say but that if treatment
could be undertaken much earlier, some congenital deficients might be
saved from being classed as such ?

We have found thymus useful in epilepsy in some cases, but, as in
all things in epilepsy, it appears harmful in others. One case, which has
been taking thymus for some years, averages many more fits if this is
suspended for a time, and takes some months to fully recover the ground
lost when the gland is resumed. Thymus causes a retention of calcium,
has some control over the formation of acids, and is largely concerned
with the phosphorus metabolism, by any of which means it may
influence epilepsy. We have also found thymus useful, as regards both
sexes, in cases of increased sexual irritability ; here it probably acts by
diminishing ovarian, thyroid, or pituitary secretion; an over-action of
any or all of these will excite the sexual organs.

Thyroid, in addition to its well-known action in cases of athyroidism,
has been proved of extreme benefit in cases of primary dementia,
chiefly those of hebephrenic type. When given as advised by
Drs. Davidson and Johnson (18)— i.e ., in rapidly increasing doses up
to 80 gr. per diem —remarkable results have been obtained. The
authors do not say how the changes come about and many of the cases
cured are certainly not of the athyroid type, and it is probably not the
thyroid per se that does the good. Thyroid is a stimulant to most of
the other glands, especially of the sex-gland, which has been shown
to be often of diminished activity in primary dementia ; it also stimu¬
lates the suprarenals and pituitary, and it is likely that in this way
the beneficial results are brought about. This mode of treatment
is not altogether safe, as it may light into activity an undetected and
unsuspected tubercular lesion. Smaller doses of thyroid combined with
suprarenal and perhaps sex-gland may in some cases bring about the
same result, as is instanced in Cases 14 and 21.

Suprarenal combined with thyroid has been of great use in the cases
just mentioned. We think the partial disappearance of the oedema
in Case 30 must be attributed,to adrenalin; the doses given were large
and long-continued and there were no persisting toxic symptoms. It
has been of value in some cases of epilepsy of asthenic type and in
LXVI. 3

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34 CASES WITH ENDOCRINE CONSIDERATIONS, [Jail.,

some old cases of alcoholic origin. It appeared to be of special value in
Case 61, who was a lad, aet. 9. Six years previously he had been
given a dose of diphtheria antitoxin because there was diphtheria in
the family. Two months later epileptic fits commenced; the attacks
for the first four or five years averaged from five to seven a week.
For eight months before admission he had from fifteen to forty attacks
daily—mostly minor ones—but had an occasional major attack. On
admission he was mentally fairly bright and he had several scars on the
back of his head from falls. He had a well-marked white dermographic
reflex; the hands and feet were bluish and cold, otherwise the physical
signs were normal. In the first month after admission he had 562 fits,
would lose consciousness and fall if not supported, but did not
often convulse. He was given suprarenal gr. v daily and bromide
and calcium. He had 303 attacks during the first month of treatment
and eleven during the second month and has had none since, now
twelve months. During the first three months he gained 14 lb. in
weight.

We have found parathyroid very useful in some epileptics and in
some its continued use seems necessary for their well-being. One of
our cases, while taking this together with bromide, had but one fit a
month, and without the parathyroid the number of fits rose to seven
or eight a month. This gland has proved useful in all cases of
myoclonic epilepsy in which we have used it.

We have entered into the uses of pituitary when describing apituitary
epileptics, but we have not given it an extended use in other mental
cases. We gave it with calcium to two primary dements with pro¬
longed periods of amenorrhoea with the idea of stimulating the ovarian
function. One of these girls menstruated after a month’s treatment,
the other after several months. Both made considerable physical
improvement, but neither improved mentally.

We have had some cases of temporary—but no lasting—benefit
from varium and didymin.

Cases 1, 2, 3 and 4 are all epileptic patients of apituitary type. Cases i, 2,
and 4 are about 5 ft. 2 in. in height and weigh from 13 st. 11 lb. to 13 st. 8 lb. ;
Case 3 is 5 ft. 5 in. in height and weighs 12 st. 9 lb. Cases 1, 2 and 3 show
deficient growth of body and face hair, their maxillary hair is absent or extremely
scanty, the hair about pubes is of effeminate formation and there is no hair growth
otherwise upon the body or limbs. In Case 4 there is a more abundant hair
growth both on face and body. In all four the mammary glands are large and
pendulous, the hands and feet are rather small and clubbed, the genital organs are
undeveloped, the supra- and infraclavicular spaces are obliterated and the fat
distribution generally is as in the female. Their blood-pressure is rather low, the
highest in the standing position being 115 mm. Hg. in Case 1 and the lowest was
95 mm. Hg. in Case 2. In their dermographic reaction Case 1 gives no reaction ;
2 and 4 show a distinct white reflex, continuing for seven minutes in Case 2 and
for three and a-half minutes in Case 4.

Of their blood examinations Case 1 gives an average of 7,800 leucocytes per c.mm.,
with a differential count of polynuclear leucocytes 71 per cent., large mononuclear

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BY GUY P. U. PRIOR, M.R.C.S.

cells 5 per cent., small mononuclears 24 per cent., hemoglobin 90 per cent. Case 2
gave an average leucocyte count of 12,000, of which the polynuclear leucocytes
were 64 per cent., large mononuclears 5 per cent., and small mononuclears
31 per cent., a hemoglobin content of 80 per cent. Case 3, leucocytes averaged
11,300 per c.mm.; the polynuclear leucocytes were 74 per cent., large mononuclears
4 per cent., small mononuclears 22 per cent., hemoglobin content 80 per cent.
Case 4, leucocytes averaged 10,500 per c.mm., with polynuclears 76 per cent., large
mononuclears 8 per cent., and small mononuclears 16 per cent.

Falta, in describing the blood condition found in apituitarism, says
the red-cell count is slightly reduced and haemoglobin about normal.
Leucocyte count often reduced, sometimes increased. Of the differ¬
ential count he says that the neutrophilic cells are reduced and the
mononuclears, especially the small, are increased (19).

Cushing states that there is in these cases a low temperature, which
can be raised by an injection of pituitary extract (20).

In Cases 1 and 2 the temperature was taken twice daily for four days. In
Case 1 it varied between 97'4° and 98'2°F. On the fifth day they both had an
injection of pituitrin. Four hours after the temperature in Case 1 registered F.
The temperature of Case 2 varied between 97'4° and 98° F., the latter being
recorded only once. He rose to 98’2° F. four hours after the injection.

Although these four patients are by their general make-up and contour typical
of apituitarism, and the fact that they are epileptics rather bears out the diagnosis,
for this disease is often accompanied by epilepsy, the results of examinations of
their metabolic processes is not altogether consistent with this.

Falta says that in hypophysial dystrophy the carbohydrate assimila¬
tion limits are raised and that there is no inclination to glycosuria, but,
on the contrary, an abnormally high tolerance to carbohydrates ; he
states that Cushing found an abnormally low abiount of blood-sugar.
In two cases mentioned by Falta the amount of blood-sugar was
normal. He obtained no sugar urinary reaction after injections of
adrenalin (21).

Our tour cases gave a glycosuric reaction in their urine after an injection of

x of adrenalin. On a second occasion Cases 1 and 3 were given an injection
of m v of adrenalin and their blood-sugar examined before and two and a-half
hours after the injection. Case 3 showed a trace of sugar in his urine before the
injection and a large amount after. His blood-sugar was 'll per cent, previous to
the injection and '14 per cent, two and a-half hours after, both being greater than
would be expected in a case of this type. Case 1 gave no urinary reaction to this
lesser dose of adrenalin, but his blood-sugar rose from "I to '12 per cent.

Case 3 was found to have a persistent glycosuria, which varies from a slight
trace to '37 per cent. His blood-sugar in ten estimations varied between ‘13 and
'21 percent. His glycosuria rose after a fit in all times observed but one. On
five examinations his urine was found to be free from sugar; on four occasions
this immediately preceded a fit, and the fifth time was after a fit. The changes
in his blood-sugar apparently bore no relationship to the epileptic attacks. His
general condition is good; he has no polyuria. Twenty-four-hour specimens
having been collected for fifty days, during which time the largest amount passed
being 1,278 c.c., there generally being in the twenty-four hours between 500 and
800 c.c., with a specific gravity in the neighbourhood of 1,020. No glandular
treatment influenced the daily quantity of sugar. He was given pancreatin under
the idea that the pancreatic secretion might be deficient; he also received pituitary
and thyroid without benefit to the glycosuria or epilepsy. The glycosuria is easily
controlled by diet.

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Case 5 was a case of similar kind except that he was more dwarfed and fatter,
showing the same physical conformation and very undeveloped genital organs.
He was aet. 28, and died suddenly shortly after taking a fit and without any
apparent cause that could have been thought sufficient to cause death. A post¬
mortem examination was made about twelve hours after death. The brain showed
nothing appreciably abnormal, the sella turcica was ill-defined and shallow, the
pituitary body was very small, and the pineal gland was described as being small.
The heart was small and fatty, but showed no fatty infiltration. The abdomen, inside
and out, was very fat. The spleen, liver and pancreas appeared normal; both
kidneys were small and lobulated like that of a horse. A persistent thymus
gland was found in the midst of fatty tissue. Some of these glands were examined
microscopically, but unfortunately the pituitary was lost. The testicular inter¬
stitial cells were reported deficient, the thymus to be acutely congested and the
suprarenal to show signs of under-activity. The thyroid was normal.

Case 6 is one of interest on account of her history. She is a female patient,
aet. 18, is well nourished, with small hands and feet, smooth skin, hair smooth
but has been falling out for the last twelve months, pulse 80 per minute, blood-
pressure 115 mm. Hg. There is a tendency to hairiness on the lower limbs, and
on the abdomen there is a dark line from the umbilicus to pubis. The thyroid
gland is distinctly enlarged. She had convulsions in infancy; suffered from minor
epilepsy from five to fourteen years of age; at sixteen, at the time the menses
should have occurred, she had a major epileptic attack, and has suffered from
these at increasingly shorter intervals since. Menses appeared at twelve years of
age, was always irregular, but since the recurrence of the epilepsy the periods of
amenorrhcea have been longer, and sometimes persist for four months. If the
period does not occur somewhere about the proper time she has epileptic attacks,
which are preceded for about two days by a feeling of “ illness and heaviness."
Her mother has exophthalmos, and had a large thyroid removed three years ago,
and which was not noticed until four years after the birth of the patient. A
paternal cousin is an epileptic. The points of interest in this case are the fact of
the mother suffering from glandular affection, and the fact of the menses becoming
more irregular as the epilepsy became more established. This might point to the
two having a common cause.

•

McKinnon, Johnson and Henninger, after describing alterations in the
clinoid processes observed in many epileptics, say that it is probable
that a moderate degree of hypopituitarism exists in all epileptics, and
that epileptic attacks are probably precipitated by sudden cessation of
practically all secretion from the posterior lobe.(2 2)

The pituitary gland has a stimulating effect upon the ovarian function,
and irregular menstruation is common in apituitarism.

Cases 1, 2, 3, 4 and 5 are of weak intellect, but fairly bright, and occupy them¬
selves usefully. Case 4 is, and 5 was, extremely irritable, and will fight and
quarrel with the slightest provocation. Case 6 might be considered of normal
mentality; she was smart at school, good at games, and said to be thoughful of
others, but occasionally irritable with children.

Cases I, 2, 3 and 4 have been treated by us for epilepsy, and 6 was removed
from our care to be treated by Christian science. There are several cases of
epilepsy that have been 'reported as having been cured, or greatly benefited, by
anterior pituitary extract, the doses being from gr. viii to gr. xxx daily.

Cushing mentions 13 cases of apituitarism associated with epilepsy;
7 of them presented uncinate symptoms. All of these suffered from a
cerebral tumour. Two followed upon a fracture; the others were con¬
sidered to be primary glandular hypoplasia. The traumatic cases did
well on glandular treatment. He treated some of these cases with

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BY GUY P. U. PRIOR, M.R.C.S.

whole-gland pituitary, giving as much as from 36 to 300 grains daily.
They improved mentally, lost weight, and the epileptic seizures were
either suspended or greatly diminished.^) We have had no success
in treating these patients either with pituitary extract or with glands
that might act indirectly upon the pituitary. We have not given the
pituitary in the larger doses above recorded.

Case 7 is an occasional epileptic, dull and demented, upon whom no special
observations have been kept. His general conformation is much the same as
in the preceding patients except that he is taller. He was not admitted to a
mental hospital until he was seven years old, and was then too demented to give
any reliable history ; probably the failure of his pituitary action and his epilepsy
are of late development, and due to arterial change in the neighbourhood of the
pituitary gland.

Case 8, an imbecile lad, aet. 15, measuring 5 ft. 2\ in. and weighing 9 st. 4 lb.,
cannot read. He knows some letters but not others, knows figures, but cannot
do the simplest addition. He is quiet and good-natured, but easily led into
mischief by others more evil than himself. His general appearance is effeminate,
and his palate high and narrow. In three examinations his blood-sugar varied
from '12 per cent, to ’14 per cent. Two hours after an injection of adrenalin nvvij
it dropped from ’14 per cent, to 'll per cent. He gave no sugar reaction in his
urine to five hours after the injection; he has no polyuria. In the blood-counts
his leucocytes averaged 12,000 per c.mm. The polynuclears were 76 per cent., large
mononuclears 6 per cent., and small mononuclears 18 per cent.

Case 9, a Greek, aet. 37, 5 ft. 6i in. in height, weighed 16 st. 4 lb. He has vivid
hallucinations of hearing and delusions of persecution. For the most part he is
depressed and quiet, but subject to certain attacks of impulsiveness and violence.
His genital organs are much atrophied. In this respect the photograph is not
much good, as the penis is almost imbedded in fat, and cannot be recognised as
such. His skin is smooth and hair-growth abundant. He is a difficult case to
place from a glandular aspect, but might be considered a mixed one, in which an
apituitary and athyroid action play a part, with perhaps an over-suprarenal action,
accounting for the excess of hair-growth, and his blood-pressure being as high as
140 mm. Hg. In 1913 he greatly improved on the thyroid treatment, as advocated
by Drs. A. Davidson and H. H. Johnson, but lapsed back after a few months, and
since then it has not been possible to renew the treatment as any attempt to do so
greatly accelerates his pulse. Treatment with thyroid and pituitrin and pituitrin
alone has been without results.

Case 10 was a lad, aet. 13 when admitted. Two years previously he had been
knocked down by a motor-car. He was unconscious for five days, and when he
regained consciousness he had a double internal strabismus, and complained that he
could see one object several times at once. Before the accident he had been a
normal boy of gentle disposition, obedient, and generally amenable, and well up to
the average at school. After recovery from the accident he became absolutely
untruthful and quite irresponsible, and it was found impossible to further educate
him. Twelve months after the injury he had fifteen epileptiform fits in one series.
After this his mental failure was more noticeable; he would wander away and
forget to return, became cruel to animals, committed male sexual practices and
his memory failed greatly. He was admitted in June, 1916, was then nicely spoken
and of attractive appearance, but absolutely devoid of moral sense ; would thieve
and lie in a most pleasant and natural manner. His memory was very deficient.
He had a remarkable chest development, with an expansion of 3 in. His hands
and feet were rather large, and the development of his organs of generation out
of all proportion to his age, otherwise he was about normal physically. About six
months after admission he became less alert and less talkative. His hair, which
had been fine and glossy, became coarse and thin, also his eyebrows became much
finer. His skin reflex, which had been red, continuing for several minutes, changed
to a distinct white, also lasting some minutes. He has, about every six months,
a series of four to five fits within a few hours, which leave him mentally dull and
confused for some days. Blood-counts made in February, 1917, gave an average

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leucocyte number of 7,637 per c.mm., of which the polynuclears were 61 per cent.,
small mononuclears 26 per cent., and large mononuclears 13 per cent. Another
differential count made a month later gave polynuclears 51 per cent., small lympho¬
cytes 27\5 per cent., large lymphocytes 12 5 per cent., eosinophiles 3 per cent.,
large hyaline 5 per cent., mast-cells 1 per cent. The blood-sugar ranged from
■07 per cent, to 'll per cent., and a slight trace of sugar was found in the urine
one and a-half hours after subcutaneous injection of adrenalin >nvij- After
receiving thyroid gr. A twice daily for four months a great improvement was noticed
in his condition generally; he became brighter and the memory improved, though
his moral character became no better. The change in this lad followed a severe
head injury. It is probable that by this injury he received damage to the pituitary
body, the sexual over-development activity and perversion being explainable by an
irritative lesion of the anterior lobe, the effeminate ensemble to a want of secretion
of the posterior lobe, the symptoms of the athyroidism being secondary to those of
the pitituary. An X-ray picture of his skull was taken, and it was reported to
show no abnormality in the region of the sella turcica or elsewhere.

Case 11 is another apituitary patient, a woman, aet. 32, and congenitally weak-
minded. She was at school for three years and can only read and write but little.
She is 5 ft. 1 in. high and weighs 15 st. 10 lb. Her chief characteristic is her
irritable temper. There is here some resemblance to an athyroid case, but her hair
is thicker and more glossy, her skin is smooth and moist, and in spite of her weight
she is an active worker and fairly quick in her movements. Her menstrual function is
normal and regular, commencing at eleven years of age. For four months she took
thyroid, gr. x daily, her weight dropping to 13 st. 10 lb. For the last twelve
months she has been having from 2\ to 5 gr. of thyroid daily; while on this she is
brighter mentally and less quarrelsome and her weight keeps at about 14 st., and
rises to over 15 st. if the thyroid is discontinued. The thyroid acts in these cases
by stimulating the patient’s own pituitary gland action.

The next two cases show signs of over-suprarenal action. Case 12, an old lady,
ait. 78 at the time of her death, was of very masculine appearance and possessed a
deep male voice. She had been an asylum patient for twenty years, and all that
time in a condition of chronic mania and constantly pugnacious. On post-mortem
examination her heart was found to be enlarged and fatty, with soft muscle and
atheroma of its vessels, the aorta being free from atheroma. The kidneys were
cystic and granular. The pancreas was large with a great deal of fat, and no
definite division between the gland and the fat. The ovaries were almost com¬
pletely atrophied. The thyroid weighed 2 dr. and each suprarenal 3 dr. It was
reported microscopically that the thymus showed no glandular elements. The
pancreas was extensively atrophied and the suprarenals degenerated. The thyroid
was inactive. Her masculine ways and appearance could be explained by over¬
action of the suprarenals, which had probably lately atrophied from age, and this
would account for the extreme atrophy of the ovaries and the activity of the
thyroid. The pancreas or suprarenals may have been originally at fault, their
action being antagonistic. The patient's age was such that degeneration of all
glands might be expected, so the autopsy is not of the value it would have been at
an earlier age.

Case 13 is a demented epileptic of longstanding. She shows fairly well-marked
male secondary sex characters. Her condition may have been brought about by
an over-suprarenal or a diminished ovarian action.

Case 14 is a small-headed imbecile, aet. 31, with an abundant hair growth over
his body. He would lie about all day, could hardly be roused, would not converse,
had no interests, was quite indifferent to all things, and was of faulty habits. His
blood-pressure was under 100 mm. Hg., his blood-count about normal, but the
small mononuclear cells were nearly as many as the polynuclear, the blood sugar was
■05 per cent., and there w r as no urinary reaction to 5 minims of adrenalin. The
dermographic reaction was white. We looked upon him as a case of over-supra¬
renal activity which had passed into one of under-action. He was given thyroid,
from gr. \ to 1 daily, and an injection of adrenalin mv-x on alternate days.
This was continued intermittently for three months. The change was gradual but
great. He is now lively and bright, will converse freely, is a keen card-player,
employs himself usefully and has made two attempts to escape. The glandular
treatment has changed him from a vegetative to an active, if not intellectual,

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individual. He is probably now as of good, if not better, mentality than at any
period of his existence. After improvement was manifest some estimations
were made upon his blood-sugar, when it was found to vary from '05 to '16 per
cent. In three leucocyte counts made at this time the average was 12,000, of
which the polynuciears were 62 per cent., small mononuclears 31 per cent., and
large mononuclears 3 per cent. He now gave a slight urinary sugar reaction to
adrenalin ntx.

Case 15 is an unintelligent woman, at. 37, whose general appearance is like that
of a boy of eighteen years of age. She has no mammary development, no axillary
hair, and the hair on her head is thin and fine. The skin is darkly pigmented in the
axilla, around garter lines and on forearms. There is no dermographic reaction ;
the thyroid and thymus are not detectable. She has never menstruated, and it is
reported that her ovaries and uterus are infantile. This is a case of mixed glan¬
dular dystrophy, the ovaries and thyroid, as shown by want of physical and sexual
development, being primarily at fault, though there is a general want of gland
activity.

Case 16 was ast. 58 at the time of her death. She was admitted to Callan Park
Mental Hospital in 1889, suffering from melancholia which had followed upon a
short attack of .mania. Melancholia has been the predominant mental symptom
since, accompanied in later years by a progressing dementia. She is a typical case
of myxcedema, with rough dry skin, thickening of the subcutaneous tissue, thin
scanty hair, absence of eyebrows, the acute susceptibility to cold, slowness of
thought and action, and general apathy. She had been taking thyroid gland
for many years. It is noted that in 1894 and 1896 she was treated with this
drug but that no improvement followed. In 1903 she was again treated with
thyroid and with much benefit, becoming less depressed and more lively. From
this time to the time of her death she was almost continuously having gr. v-x
of thyroid daily. If this was discontinued for a short time she put on weight,
became so dull and uninterested that she would not even move of her own initiative,
became silent and would be faulty in habits. While taking the gland, although
depressed and morose, she would dress, take food, and look after and even occupy
herself. In July, 1917, she had four epileptiform convulsions in quick succession
and died two days afterwards. At the post-mortem examination there was much fat
everywhere, which made it difficult to define the limits of some of the glands, which
were themselves impregnated with fat. There was very little thyroid tissue, and
what there was was ill-formed and degenerate. The thymus tissue was also much
degenerated; the spleen was small, weighing 4 oz.; the kidneys lobulated, otherwise
healthy. The heart was fatty and the arteries very atheromatous. After micro¬
scopical examination it was reported that there was no evidence of active thymus
tissue, and that the ovaries, suprarenal and pituitary showed signs of much under¬
action.

Case 17 is jet. 14 and Case 18 is aet. 32. Both are simple and childish, incapable
of being educated, and both delight in playing with dolls. Case 17 is a Mongolian,
with the hands and feet, dry skin and scanty hair of athyroidism. She has an
insane inheritance. She learned to walk at seven and to talk indistinctly at nine
years of age. She was very irritable and dribbled much. She menstruated at
13J years, and at this time developed secondary sex characters and also sexual
inclinations, for which reason she was removed from her home. On from
gr. i to 2 of thyroid daily she made improvement, she grew and gained in weight,
the condition of the skin and hair improved, the dribbling habit ceased, and she
became quite talkative and talked more freely and clearly. It has been possible
to teach her to scrub, fold clothes, and generally help, which she does fairly
well and with much pleasure.

Case 18 was of rather different type, the skin and hair being normal; the hands
and feet were small, but not of the stubby formation of the former patient. She
was of low intelligence, could not talk distinctly, and could understand but
little of what was said to her. She suffered from attacks of tetany which were
associated with the menses. She died of cerebral abscess secondary to middle-ear
disease.

Case 19 was a case of gonod deficiency. The genital organs are infantile, the
breasts are large and pendulous, the fat distribution is of feminine character, and
there is a poor growth of face and body hair. The hands and feet are small and

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slender, the pelvis large and well formed, the voice high pitched and of peculiar
intonation. He was seventy years of age when his photograph was taken and was
admitted seven years previously. His intelligence is very limited and his con¬
versational powers are almost nil.

Cases 21 and 22 are both aet. 16, but have developed very differently.
Case 21 is 5 ft. 4^ in. in height and weighs 9 st. 8 lb., while Case 22 is 4 ft. 8J in.
and weighs 4 st. 2 lb. Case 21 made but little progress at school but is stated to
have been a good industrious girl in the house. Six months before admission she
became dull and listless, and talked nonsense to herself in a muttering tone, but
otherwise moped about taking no notice of anything. The menses, which had
hitherto been regular, became irregular and scanty, and she is said to have lost
weight. The symptoms followed upon a " heavy cold.” On admission she was
very dull, would repeat but would not answer questions, and was quite indifferent
to her surroundings. She passed urine apparently unconsciously, wetting her bed
during the night and her clothing during the day. She was well nourished, skin
smooth, soft and active, hair normal, hands and feet cold and damp. The pulse
was 88 per minute, and the blood-pressure was 120 when standing. The dermo-
graphic reflex was white, continuing for ten minutes. For six months she was
given suprarenal gland gr. v, and made rapid improvement. She became bright
and industrious and gained more than two stone in weight. Because of this gain
in weight and there being no symptoms of athyroidism she was given pituitrin and
varium, but continued to gain weight and weighed 12 st. 3 lb. when she left the
hospital eighteen months after admission. Her mental improvement has been
maintained, her mother reporting that the patient has never been so well as at
present. In this case there was probably some dysfunction of the suprarenals
following upon the " heavy cold,” this being followed by diminished ovarian
action.

Case 22 is a very dissimilar one. She has been a hospital patient since she was six
years of age, and at that early age was given to violence. At the present she
appears about ten years of age, speech is very imperfect, no axillary hair, mammary
development is poor, and skin and hair are normal. The thyroid gland can be felt,
but the thymus cannot be detected. Chvostek reflex is present. The knee-jerks
are exaggerated and there is left ankle clonus. Dentition is good. Though of
childish and pleasing appearance she is a most evil minx. She will attack anyone
without reason or malice, will trip up or push down the old and feeble and will
come up smiling and spit in one’s face. She is filthy in habits, and throws faeces
about her room and has not menstruated. There is no special sign of glandular
deficiency. She is undeveloped both mentally and physically, the under develop¬
ment in this case being of cerebral origin.

Case 23 was aet. 18 on admission, 4 ft. 8 in. in height, and weighed 5 st. She
has but little intelligence, cannot read or write, and, although expressing a wish to
learn, on sending her to school it was found impossible to teach her. Physically
she is undersized and undergrown ; she has a peculiar growth of fine hair all over
the body, with but little axillary hair. There is a line of pigment on the abdomen
from the umbilicus to the pubis. The mammary development was poor on admission
but had increased six months later. Her thyroid gland cannot be felt. The
thymus is enlarged and can easily be percussed out. The bones are small and
slender, as are the hands and feet. The skin is smooth and soft, the sweat-glands
of axillae being abnormally active. The pulse was 88 per minute. She has a
slight intermittent glycosuria, which was found on testing her urine previous to
an injection of adrenalin. Her blood-sugar at this time was '14 per cent .; two
hours after the injection it had fallen to '05 per cent., the excretion of urinary sugar
being much increased. The haemoglobin content is about 100 per cent.-, the
leucocyte count averages 10,000 per c.mm.,the polynuclear cells being 76 per cent .;
small mononuclears 11 per cent., large mononuclears 7 per cent., eosinophiles 4 per
cent., masts and hyaline cells 1 per cent. each.

It is difficult to determine whether a thymus in this, and similar cases, is
primarily enlarged, or secondarily, as either compensatory or inhibitory to some
other gland. What results the enlarged thymus has upon growth and formation
probably depends upon the amount of over-action, the effects upon other members
of the endocrine system, and the time of life at which the enlargement occurs.
This case was treated for some months with suprarenal extract gr. v and gr. J

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Original from

PRINCETON UNIVERSITY

BY GUY P. U. PRIOR, M.R.C.S.

1920.]

thyroid daily. Except that she gained 8 lb. in weight and that her mammary
development has increased there has been no noticeable change.

Cases 24 and 25 are similar in their mental, but very different in their physical
make-up.' Case 24, who is set. 14, is 5 ft. 10} in. in height and weighs 10 st.,
while the other case is a year older, 4 ft. 10 in. in height and weighing 6 st. 10 lb.
Both these boys had been to school, and although they had not done well, had done
fairly, and had commenced to earn their own living, Case 24 on a dairy farm and
Case 25 in a boot factory, and both were spoken well of by their employers. After
doing well at their work for a while they each took to wandering from home and
would remain away for days, seemingly doing nothing but walking the streets and
sleeping in empty houses or out-houses. Each would rob their parents before
starting from home, but had not been known to rob anyone else, except Case 25,
who, living in an orchard district, admits taking fruit for food. In each case the
thyroid could be felt, while Case 25 had an enlarged thymus but not Case 24. Case
24, whose bones were large and thick, hands and feet large, and genitals of abnor¬
mal development, might pass as one of over-pituitary action and was treated with
didymin to lessen this activity. The other lad has a generally diminished glandular
activity, with the exception of the thymus, which may be keeping the others in
check. Case 24, in three blood-counts, gave an average leucocyte count of 10,000
per c.mm. with polynuclears 52 per cent., small mononuclears 43 per cent, and large
mononuclears 5 per cent. He gave a slight urinary sugar reaction two hours after
an injection of adrenalin The blood-sugar on two examinations was '05 per

cent, while on a third it was‘14 per cent. This was previous to the adrenalin
injection, after which it fell to ‘11 per cent. No blood observations were made on
Case 25.

The two boys soon returned to their normal mentality and left the hospital after
six months’ residence. Case 24 has been out more than twelve months and is reported
to be doing well. Case 25 was returned after being away a month, as he was
inclined to wander and did not settle to work. About a month later his parents
insisted on removing him to a Salvation Army home, and to us he has been lost
sight of, but he should be doing as well as his companion.

Case 26 is set. 18, weighs 7 st. 12 lb., and measures 4 ft. 9J in. His hair and
skin are normal, and his bones short and thick. He has a fair amount of sense, is
capable of useful occupation, but has no initiative. He has no idea of the value
of money, is easily led into mischief, and readily becomes a tool of others, which
was the reason of his admission. This is a case approaching achondroplasia. He
contrasts with the cases 27, 28 and 29, three Mongolian imbeciles, with the spade-like
hands and feet, the rough dry skin, thick lips, and undershot jaws, scanty dry hair
on head and deficiency of body hair. Case 29 gives a distinct white skin reaction
lasting ten minutes, and passes about 3,000 c.c. of urine in twenty-four hours. His
leucocytes average 6,500 per c.mm., the polynuclears being 58 per cent., the large
mononuclears 14 per cent., and the small mononuclears 28 per cent. In three exam¬
inations his blood-sugar varied from ‘05 per cent, to ‘15 per cent. After an injection
of n\_ x of adrenalin his leucocytes rose from 5,062 to 24,750 per c.mm.; there
was a slight rise in the blood-sugar but none excreted in the urine.

Case 28 was 5 ft. 10 in. in height, and died of colitis at the age of 45. At
the post-mortem examination, made twelve hours after death, his brain was found to
weigh 39 ounces; his heart was normal, except that the aorta would only admit
one finger. There was a considerable amount of thymus tissue scattered about
the mediastinum. The thyroid was small, the suprarenals were large, but were
apparently mostly fatty tissue.

Case 64 is one of a peculiar oedema, and follows fairly exactly the description of
Milray’s disease, but there is no hereditary history. She was first admitted to a
mental hospital in December of 1911. Her mental condition had been diagnosed
as recent mania, and moral insanity. She had been sent to a reformatory at quite an
early age and at eighteen she went into service, and shortly after eighteen had a baby.
In January, 1914, she was treated for retroflexion of the uterus, pyelitis and cystitis.
She was subsequently treated for a double salpingitis and later a left salpingo-
oophorectomy was performed. Later in the same year she suffered from gonorrhoea.
She came under our care in March, 1916, and was then in good physicial health. In
April of that year she complained of pain in the right hip-joint, after which for
three months she persistently complained of pain in one of the joints of the right leg.

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CASES WITH ENDOCRINE CONSIDERATIONS, [Jan.,

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Towards the end of July the right ankle-joint was swollen and at this time it was
noticed that she had a few pus-cells in her urine and some diplococci. In
November, 1916, the right leg from the hip to the ankle was swollen and oedematous.
The blood was repeatedly examined for filaria, but with negative results. In
January of 1917 the leg was very swollen and she complained of severe headache.
A lumbar puncture was performed and 17 c.c. of fluid was removed under a plus
pressure. Three days after the puncture the leg was almost normal, but had
returned to its original degree of oedema within the next week. In October of
1917 the left leg below the knee became oedematous. The next month the left leg
and thigh were oedematous, as was the right. A silk-worm-gut drain was put into
the inner surface of both thighs, but no benefit followed this, although they drained
freely for a time. A lumbar puncture had been repeated once or twice but never
with the same result as the first time. In February of 1918 several incisions were
made into the legs, which drained freely, but they did not diminish in size. About
this time numerous hard round nodules developed ; they were very tender to
touch. Two were removed and examined under the microscope but no lepra bacilli
were found. In this month the right arm became swollen, and there was a tender¬
ness along the course of the nerves. In March she complained of a great deal of
temporal headache. Twenty c.c. of cerebro-spinal fluid were removed under
increased pressure, after which the headache improved, and the legs became
smaller, though nothing like normal. In April of the same year she complained
of much abdominal pain and often vomited. The headaches again became severe.
A lumbar puncture was repeated with relief to the headache, but it was not
followed by any lessening of the swelling of the legs or arm. Injections of
adrenalin rnx and calcium iodide gr. xv were given into the scapular region
every second day for a fortnight. The swelling in the legs became much smaller,
the decrease being most marked the day after the injection. She then objected to
the injections and they were discontinued. Between May and September the
injections were repeated several times for about ten days or a fortnight at a time,
each time with much diminished swelling of the legs, more especially the left; the
thighs at one time became normal. When the oedema was diminished the patient
complained of very much more pain in the legs. In October of 1918 six injec¬
tions of pituitary, 1 c.c., were given on alternate days and after the second dose
there was some improvement, but this was not lasting. In December of the
same year the right arm began to swell—first the hand and forearm, then above
the elbow. Another series of injections of adrenalin and calcium were given, the
two drugs this time being given separately. The patient became resistive and the
treatment was discontinued. After these six injections there was marked improve¬
ment. In January of 1919 the left arm also commenced to swell and the right
became bigger still. During the next month both arms and both legs were
extremely swollen, and she was unable to move any one of the four limbs.
The patient now implored to have the treatment resumed, and this was only con¬
sented to on the condition that she would be treated as long as was thought
necessary, and that she would take and do all things as told. She was given 1 c.c.
of adrenalin, and this was repeated every second day. By February 18th the left
arm and hand were normal, the right hand nearly so, the swelling of the left leg had
disappeared except of the foot and ankle, the right leg was smaller, and the
oedema softer, and would now pit on pressure. Always before, when patient’s
legs were going down, she had vomiting attacks and severe abdominal pain, but
this time these were not so severe, but she complained of a great deal of pain in the
limbs as the oedema diminished. In March of the same year both hands and arms
were normal, and she had free use of them. The left leg was also normal. From
July the adrenalin injections were continued for ten weeks. They then caused
giddiness, breathlessness, and much pallor of the face, so they were reduced in
frequency and amount, and afterwards discontinued. Suprarenal tabloids gr. xv
and gr. i of thyroid daily were substituted. The improvement has been slow but
continuous, and there has been no return of the oedema of the upper extremities.
That of the lower limbs has persisted, though it has been much more variable,
the degree of swelling altering from day to day. The patient’s mental condition
has undergone a great change for the better. She is now affable and cheerful,
whereas formerly she was most morose and taciturn.

The differential diagnosis of this case is by no means easy. The patient at times

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Original from

PRINCETON UNIVERSITY

1920 .]

BY GUY P. U. PRIOR, M.R.C.S.

during her illness was extremely resistive both to treatment and examination, for
which reason observations upon the chemistry of her blood and urine have not been
made. In the earlier stages of her illness she was thought to be suffering from
gonorrhoeal rheumatism, and finding diplococci in her urine supported this supposi¬
tion, which could not be maintained when the leg became generally oedematous.
The diagnosis then rested between an oedema of venous or lymphatic origin. No
filaria could be found in the blood nor could any cause for a venous block be found.
It was self-evident that the oedema was not of cardiac, portal or kidney origin,
though there was often a trace of albumen in the urine. An angio-neurotic oedema
was considered, but as a rule the (edema in these cases comes and goes quickly,
attacking first one and then another site. Later when two and then a third limb
was attacked, the case exactly resembled one of Milray's disease, which is described
as an oedema which first attacks one limb, then another, until all four limbs are
affected; it persists until the patient either dies from exhaustion or from some
intercurrent disease. According to descriptions, the one essential of Milray’s
disease is that it is hereditary, but no hereditary history could be obtained in this
case either from the patient or her friends, her parents having died when she was
quite young, the family separated and were brought up by the State, and so no
great reliance can be placed upon the family history. No pathology has been given
to Milray's disease.

(Edemas, sometimes persisting, sometimes very transitory and without any
apparent cause, or with such insufficient cause as long standing, are not uncommon
in the insane, though the pathogenesis of these have not, as far as we are aware,
received much attention as yet.

We look upon this case as likely to be due to some lesion of the sympathetic
nervous system. We gave her adrenalin underthis idea, and the calcium because of
its action upon the blood-vessels. Her blood-pressure previous to the adrenalin
injections was within the normal range, nor was there any increase after the injec¬
tions, even when the larger doses were being given. A sign of insufficiency of her
own adrenalin system was the fact that only upon about two occasions was there
sugar in the urine, even after repeated 1 c.c. doses of adrenalin. It is advised that
adrenalin be not given repeatedly even in small doses, but in this case it seemed to
be doing nothing but good, and the case appeared so hopeless otherwise. Her
menses had been in abeyance for some twelve months, but reappeared at irregular
intervals while receiving the calcium iodide and adrenal injections and continued
fairly regularly while receiving larger doses of adrenalin.

My thanks are due to Mr. E. C. Wood for reading and correcting the
manuscript, for aid and advice in its formation, and for typing the final
copies, and also to Mr. A. Lyon, the Chief Attendant, for much help in
the laboratory and in the care of the guinea-pigs and tadpoles.

[It is regretted that owing to the prohibitive cost of reproduction
numerous other interesting photographs which illustrated this article
could not be published.— Eds.]

References.

(1) Endocrinology, vol. i, p. 133.

(2) D. N. Paton.—Ref. Regulators of Metabolism , p. 118.

(3) Endocrinology , vol. i, p. 344.

(4) Harmsworth.— Natural History , pt. 12, p. 605.

(5) McCarrison.— The Thyroid Gland, p. 144.

(6) ‘Thyroid Insufficiency,” Practitioner, January, 1915.

(7) Practitioner , February, 1915, p. 181.

(8) Endocrinology , vol. ii, No. 3, p. 336.

(9) “ Epilepsy and the Ductless Glands,” Journ. Merit, Sci., June,
1918, p. 58.

Digitized by Google

Original from

PRINCETON UNIVERSITY

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PRINCETON UNIVERSITY

TREATMENT OF GENERAL PARALYSIS,

[Jan.,

(10) Ref. Med. Journ. of Australia, June xst, 1918.

(11) Orten.— Amer. Journ. of Insanity, vol. lxxi, p. 579.

(12) Bandler.— Med. Gynaecology, p. 157.

(13) Osier and Macrae.— Modern Medicine, vol. iv, p. 781.

(14) Falta.— The Ductless Glandular Diseases, p. 336.

(15) Osier and Macrae.— Modern Medicine, vol. iv, p. 787.

(16) Harrower.— Practical Hormone Therapy, p. 2.

(17) Tobias.—Apocrypha, chap, vi, verses 2 to 17.

(18) A. Davidson and H. H. Johnston.—“Use of Thyroid Extract
in the Treatment of Mental Disease,” Aust. Med. Cong. Trans., 1911,
vol. ii, p. 8x7.

(19) Falta.— Ductless Glandular Diseases, p. 305.

(20) Cushing.— The Pituitary Body and its Disorders, p. 268.

(21) Falta.— Ductless Glandular Diseases, pp. 290 and 291.

(22) Ref. Practical Medicine Series, vol. ix, 1914.

(23) Cushing.— The Pituitary Body and its Disorders, p. 272.

Regarding the Treatment of General Paralysis. By G. H.
Monrad-Krohn, M.D.Christiania, M.R.C.P.(Lond.), Physician
to the Neurological Section of Rikshospitalet, Christiania ; Lecturer
in Neurology to the Royal Frederick University, Christiania.

When Noguchi found spirochsetes in the brain of general paralytics
some years ago it seemed as if we were entering into a new era, not
only in the pathological conception of the so-called “ parasyphilitic ” or
“ metasyphilitic ” affections, but also in their treatment. In this latter
respect most of us have hitherto been somewhat disappointed, and it
may therefore be advisable to take up the rationale of the treatment for
revision.

The reason why the usual antisyphilitic remedies are of little or no
effect in these affections may be found in one or more—perhaps all—
of the following possibilities :

(1) Either the antisyphilitic remedies or the antibodies—the forma¬
tion of which they give rise to—do not get access to the spirochsetes on
account of their anatomical localisation ;

(2) Or the spirochsetes may have acquired an immunity to the anti¬
syphilitic remedies ( J );

(3) Or the initial spirochaete affection of the cortex may have already
started a vicious circle, which per se will lead to destruction irrespective
of the spirochmtes.

(4) Finally the possibility must also be kept in mind that meta¬
syphilitic lesions may be due to a mixed infection of spirochaetes and
some other microbe or microbes ( e.g ., Porter Phillips’s diplococcus or

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Original from

PRINCETON UNIVERSITY

BY G. H. MONRAD-KROHN, M.D.

1920 .]

Ford Robertson’s diphtheroid); the fact that syphilis only in com¬
paratively few cases is followed by “ metasyphilitic ” affections shows
us that these must be due to syphilis + something else, and this some¬
thing else may quite well be a microbe. The possibility of this microbe
“carrying on ” alone after being “ introduced” by the spirochaete must
also be faced.

With the first-mentioned alternative in view one tried to inject
salvarsan solution directly into the cerebrospinal fluid, but as this
frequently led to unpleasant spinal complications, Marinesco proposed
to inject salvarsanised serum into the cerebrospinal fluid. Swift and
Ellis followed Marinesco’s lead, and lumbar puncture, followed by
injection of salvarsanised serum, rapidly gained ground as the most
rational way of treating tabes. As regards general paralysis, it was
felt that the intraspinal injections could be of no avail and different
forms of intracranial injection methods were introduced. The most
practical of these, I still venture to believe, is the one which I developed
and described in Norsk Magazin for Lcegevidenskabeti, Christiania,
No. 5, 1914, and in a letter to the Lancet in the spring of 1914 (May¬
or June as far as I remember), also in the Journal of Mental Science,
April, 1915. Schroeder and Helweg have also used this method with
some modifications ( cf their interesting article in this Journal, January,
1919(2)).

I think it is too early to draw any definite conclusion from the
experience yet gained. My own experience comprises but sixteen
cases, and the only conclusion I feel justified in putting forth is that in
advanced cases of general paralysis of the insane the proposed treat¬
ment has no appreciable effect. If in early cases it has some effect
I do not yet feel justified to express a decided opinion. Several of my
cases are “ promising,” but then the early spontaneous remissions
complicate the question post aut propter. On the whole one cannot
yet expect conclusive experience regarding the result of the treatment.
At least five years’ continued observations of a large number (fifty or
more) of early cases will be necessary as a basis for a more definite
opinion.

My object in writing these fines is therefore not to give the result
of my scanty experience, but to draw the attention to the above-
mentioned possibilities, of which it appears to me that (2), (3) and (4)
have been neglected. If an inaccessible situation of the spirochsetes
as regards the antisyphilitic remedies were the only reason of the failure
of the ordinary antisyphilitic treatment, it strikes me that we should
already now have obtained more striking results from the salvarsanised
serum treatment; even in advanced cases one would then expect an
arrest of the disease, which I have satisfied myself one does not get.
For these advanced cases I am inclined to believe in some vicious

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Original from

PRINCETON UNIVERSITY

TREATMENT OF GENERAL PARALYSIS.

[Jan.,

circle having been established leading per se to destruction (3). The
question must therefore be studied in early cases, and here the possi¬
bilities (2) and (4) must also be taken into account.

An acquired immunity on the part of the spirochaetes might possibly
be broken down by a simultaneous attack through different “haptophore
groups ”—at least experiments on trypanozomes lead us to believe so.
Consequently simultaneous administration of mercury should be com¬
bined with the intracranial salvarsanised serum method. Hexamethylen-
tetramin (urotropin) should also be given from this point of view,
and this latter modification would also help to counteract any mixed
infection (4). A simultaneous treatment with antimony might perhaps
also be tried. That the remedies advanced by McDonagh may help us
here future experience only can decide. One must keep an open,
unbiased mind, and if a number of remedies can be found which
all attack the spirochtete through the different “ haptophore groups,”
this will signify a great advance in our attempts at combating the
“ metasyphilitic ” affections.

Finally a few words about salvarsanised serum. What is salvarsanised
serum ? What is its active principle ? Some authors claim salvarsan
itself to be the active principle ; others hold that the antibodies formed
in consequence of the salvarsan injection (the death of spirochcetes and
liberation of endotoxins) form the active principle. According to the
different opinions some physicians take the blood immediately (quarter
to half an hour) after the salvarsan injection; others wait twelve hours
or more. As long as this question has not been decided I think it
safest to take the blood half an hour after the salvarsan injection. In
this way the serum will contain the salvarsan from the immediately
preceding intravenous salvarsan injection, and with repeated injections
also the antibodies formed in consequence of the previous salvarsan
injections.

We may be—and probably are—on the right way to solve the
question of treatment of general paralysis of the insane. And yet we
may fail if we do not face all the possibilities that obtain.

(') If the spirochsete has a life-cycle (as McDonagh will have it), it would not
be surprising to find certain phases of the life-cycle immune to the usual anti¬
syphilitic remedies.—( ! ) With regard to the modifications they propose, I shall
just mention that after injection of the full dose of 0'9 neosalvarsan arsenic can
be found in the blood, and anyway, it is on account of such concentration in the
blood after intravenous injections that it acts on syphilitic lesions in other organs.
Why should a stronger concentration be needed in the brain ?

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Part II.—Reviews.

My Life and Friends: James Sully, LL.D. London: Fisher Unwin,
1918. 8vo. Pp. 356. Price 12*. 6 d. net.

First of all, one must commend this book as a most agreeable
pastime, full of general interest, and also, from our standpoint, instruc¬
tive. Your reviewer has special interest in contributing something in
reference to the book, for the author and he not only belonged to the
same social club, but were both fellow Sunday tramps with Leslie
Stephen, and in many respects there was a strange parallel in their
youthful surroundings. There was also a similarity in age.

James Sully was the son of a Bridgewater tradesman, who was an
ardent Gladstonian Radical and also a Dissenter. These qualifications
to a certain extent interfered with his general social life, so that the
society in which the son of a Radical tradesman and a Dissenter mixed
was essentially unlike the society which the majority of literary men
have passed through.

To begin with, his schooling was of the most mixed kind. He was
sent to various “ dames’ ” schools, and was never at any really public
school, the result being that his education was not so much by book as
by observation and family relationships. He was particularly happy in
his family, parents and sisters all being intelligent and earnest. The
fact that he did not go to a public school and then to a classical
university turned his thoughts more on to science and to general
history and literature than otherwise would have been the case. Music
was one of the great resources of the family, and Sully developed great
taste and ability along musical lines. Later, besides taking an interest
in natural science, he also took practical interest in drawing.

He began, as I have said, in the rather narrow local schools. Later
he was under tutors and went in for the University of London examina¬
tions. Still later he went to German universities, where he formed
many life-long friendships.

His father was particularly anxious that he should become a Methodist
minister, and for many years, although he had no special religious “call”
or inclination, yet he felt that it was a useful and interesting occupation,
and in a calm, unattached way, to be a duty to pursue theological
studies. These did not seem to upset his general faith and belief until
he went to Germany, when distinctly his views were broadened or, we
may say, widened, and slowly he came to the conclusion that at all
events it was not his part to become a recognised minister. In many
ways, therefore, he and Leslie Stephen passed through parallel mental
states. Leslie Stephen became a clergyman, though he practically never
officiated as such ; and Sully was qualified as a minister, but did not
take up the duties.

Slowly Sully’s ideas passed from faith to agnosticism, and with men
like Huxley and Leslie Stephen he was a follower of higher ethics and
morality. Religious dogmata did not appeal to him.

Fortunately for him, his father was, at all events for many years,

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wealthy and able to contribute to his education, so that he travelled far
and wide and spent much time in continental schools. But he was
anxious to get some work, and he began as a journalist, and through
the influence of men like Leslie Stephen and Morley he secured
journalistic work, and he contributed an enormous number of articles
on a very large number of subjects. He did a great deal of reviewing,
and one of his first independent essays was on “ Pessimism.” This led
to a certain amount of misunderstanding, because he himself was
anything but a pessimist. But the title seemed enough to rather
condemn him in the eyes of certain people.

Later on he devoted much more time to the study of ethics and
so-called psychology. He studied Bain, Herbert Spencer, George
Lewes and W. James. He took independent views in relationship to
all their writings, and himself wrote more than one book on psychology,
the original idea being that the book should be a standard for examina¬
tional purposes. Later, this developed into the larger work, The
Human Mind , in two volumes. There is independence of thought and
careful observation in all these works. Whatever Sully was, he was an
observer and a recorder. He was not content simply to saturate himself
with the ideas of ancient philosophers, or to swallow whole the philosophy
of the modern French or German writers. The result has been quite an
independent line of thought.

Besides these, he wrote other books, some having given him a peculiar
pleasure, and certainly, to my mind, displaying the man’s character
much better than even his psychological writings. For instance, the
book entitled Child Studies is simply a further evidence of the kindly
child loving nature of James Sully. He wrote also an interesting book
from what might be called the emotional side, entitled Human Laughter.

But it is quite beyond one’s power to enumerate the thousand-and-one
articles, reviews and books that he wrote or contributed to. He was a
most voracious reader, and owing to his literary work and his writing
he suffered from a nervous breakdown and had to have a rather
prolonged rest abroad. At the same time he was suffering from his
eyesight, so that it became absolutely necessary for him to refrain from
real brain work. He recovered completely, and it was only later that
he once more went to live abroad.

He established himself at Hampstead, and at the time he was
there, there were a good number of artistic, literary and scientific
residents, who formed little social clubs, and it is quite evident that
in those days Sully was a very social person and quite capable of
enjoying good society and good dinners !

In this Life he refers to his neighbours, especially those about
Hampstead. He also refers to their social gatherings.

He had a wonderful gift of friendship, and throughout the whole
of the book it is noteworthy that there is scarcely an unkind remark
about anyone. In fact, one would say there may be slightly critical
remarks, but none that are really harsh. Evidently the temperaments
of men like Bain and Heri-ert Spencer were not congenial to him.
Men who were physically unfit, who suffered from indigestion, or were
ini apable of taking vigorous exercise, were not likely to be long friends
of Sully.

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I do not think I ever came across any book in which what might be
called the thumb sketches of character are so well given. And when
one thinks of the numbers of friends that he had made and kept, it is
certainly astonishing. A considerable number of his friends, of course,
were literary, but there were, besides, the scientific friends and many
musical ones. He was a friend of Huxley, and Darwin ; and Romanes,
who died so early, was a man in whom he was distinctly interested and
with whom he was sympathetic, though he failed to follow Romanes in
his religious thoughts. Besides those mentioned, Leslie Stephen and
George Meredith probably had the greatest influence upon his life and
conduct. He worshipped Meredith from the literary and social points
of view, and he admired Leslie Stephen, both from the philosophical
standpoint and also for his muscularity. Sully was an athletic man,
although not a powerfully built man. Yet he was good at many sports ;
he was an excellent swimmer, he did a considerable amount of climbing,
both in England and abroad. But walking probably was the thing that
interested him most, and he and I were both members of Leslie Stephen’s
Sunday tramps. His descriptions of the meetings of these tramps under
the guidance of Leslie Stephen give a very clear idea of the kind of
society that Sully sought and the society that appreciated him.

As I have said, his religious views passed from a more or less definite
faith into agnosticism. Politically he was a Radical, and I suppose may
be called a Pacifist. He was one of the very exceptional men in England
at the time of the Boer War with pro-Boer tendencies, and ran a certain
amount of risk of being misunderstood. He tried to get others of his
friends to join him in some more active demonstrations against the
Government, but fortunately in this he was over persuaded. The very
strongest views of liberty of thought, liberty of mind, and of absolute
rectitude ruled his life from beginning to end.

As one goes on with the book one is very much struck with the
tender-heartedness of James Sully. One by one his most intimate
friends, like Leslie Stephen and George Meredith, Romanes, Spencer,
Bain and others died, leaving him, if not alone, yet deprived of many
of his old friends; and as he points out, getting on in years it is much
easier to lose than to gain friends.

In conclusion, one can only say that the book is eminently worth
reading, and gives, one may say, an epitome of the social life of the
educated circles in and near London during the last fifty years, and
leaves one in the hope that Sully’s work is not yet over. He is honorary
member of the Neurological Section of the Royal Society of Medicine.

G. H. S.

Syphilis and the Nervous System. By Dr. Max Nonne. Translated
by Charles R. Ball, B.A., M.D. London and Philadelphia:
J. & B. Lippincott & Co., 1916. Second American edition,

revised. 8vo. Pp. 450. Illustrated. Price $18 net.

This volume, the second American edition of Syphilis and the
Nervous System, is a translation of the third German edition published
by Dr. Max Nonne in 1915.

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In the arrangement and in the material content of the majority of the
chapters the book differs little from the previous edition; the author
has remained true to his profession of writing from the practice for the
practice, and, as he emphasises the importance of the symptomatology
and of clinical observation in dealing with the syphilitic diseases of the
nervous system, the book, which is rich in clinical detail, remains much
as before.

The chapters on dementia paralytica and tabes dorsalis have, how¬
ever, undergone considerable modification in the light of the discovery
of the Spirochceta pallida by Noguchi, in the brain of the paretic and
in the spinal cord of the tabetic. The demonstration of the organism
of syphilis, coming with the evidences furnished by the cytological and
chemical examination of the cerebro-spinal fluid in cases of general
paralysis and tabes dorsalis, has finally settled the long-drawn-out dis¬
cussion as to the specific origin of these conditions. Nonne agrees
with the English neurologists, Mott, Head and others, that “the clinical
manifestations of parasyphilis are an expression of the reaction and
necrosis of hypersensitised areas of the nervous system, evoked by the
reappearance of the Spirochceta pallida ”; he differs, however, from
Mott’s assumption that the inflammatory condition of the neuroglia and
blood-vessels is a secondary effect of the primary nervous degenerations,
which was his opinion before the discovery of the spirochaeta in the
brain. But that is not his opinion now.

He considers that the case for a specialised strain of organism with
a specific affinity for the nervous system is not yet proven, and he
differs, on the one hand, from the view of Nacke, that the neuropathic
disposition is an important factor in the genesis of these conditions, and,
on the other, from Kraepelin in his opinion as to the predisposing
influence of alcohol.

It is of interest to note that Dr. Nonne is inclined to deny the
impossibility of recovery in paresis. He cites the occurrence of cases
“whose enrolment under the diagnosis of paresis no one would have
doubted had the termination been the customary unfavourable one.
The fact alone that the termination was favourable should not, in my
opinion, change the diagnosis.” The question, however, is a difficult
one to solve on account of the lengthy periods over which remissions
of the disease have been known to extend, and, in the cases quoted by
the author, in support of the view of recoverability, none had been under
observation for more than six years. The author, however, does not
state that the patient had not suffered from any brain deficit.

The chapter on the behaviour of the Wassermann reaction in the
blood and spinal fluid, the occurrence of pleocytosis and the increase
of globulin in the spinal fluid is most instructive. In it is given, in
schematic form, an estimation of the value to be placed on the positive
or negative findings in either case, also an authoritative statement as to
what influence the results of examination of the blood and spinal fluid
should be allowed to have in determining the prognosis and the further
treatment of the particular patient concerned. In this connection,
Dr. Nonne states that when the four reactions are all negative one may
conclude that the syphilis of the patient has really ceased to exist; he
adds that he has seen a large number of such cases. “The persistence

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of one or more of the four reactions demands a continuance of the
treatment in cerebrospinal lues. In tabes and paresis the persistence
of the three reactions in the spinal fluid is no indication for the con¬
tinuance of the treatment, for, in these diseases, the three reactions,
save in rare cases, are uninfluenced by any therapy with which we are
at present familiar.”

A special chapter has been added on the question of salvarsan
therapy. Here the whole question of the treatment of the syphilitic
nervous disease is dealt with, full details of the methods to be adopted
in the various forms of administration are given, from that for the
administration of the now somewhat antiquated original “ 606,” to that
to be followed in the intraspinous injection of salvarsanised or mercu¬
rialised serum. As regards the cases treated by the author with these
latter methods, he was unable to notice any difference in their course
than in cases treated by the usual methods.

Out of his own experience, Dr. Nonne advocates the combination of
mercurial inunction with the adminstration of the arsenical compounds.

In his conclusions as to the value of the arsenical compounds the
author is terse and to the point. He states that in cerebrospinal
syphilis in individual cases, a quicker and more far-reaching result may
be obtained with salvarsan than with mercury and iodide. There are
also cases in which salvarsan has been effective after the older remedies
have failed or have had an insufficient effect. The cases in which
salvarsan has had an entirely favourable effect are, however, in the
minority. In the majority the superiority of salvarsan over mercury
and iodide is not apparent. In tabes and paresis the newer remedy is
of no more avail than the older ones.

Dr. Nonne, though he admits the evidence pointing to the accerba-
tion of certain cases following treatment by the arsenical compounds,
deprecates the idea of any serious danger, and would not permit such
considerations to interfere with the laying down of the course of treat¬
ment. He advises commencing with the smaller doses, but considers
that the intensive treatment has definite advantages in certain cases.

Detailed accounts are given of the tuberculin, the sodium nucleinate,
and the vaccine method of treatment of nervous syphilis, though here the
author has little to say in regard to his own experience of these methods.

He concludes his chapter partly with a warning against the “Furor
Therapeuticus,” which the laboratory reports have tended to instigate.
He reminds his readers that the older and more experienced physicians
used to say that a case was refractory to treatment if a six weeks’ course
of mercurial administration did not produce recovery or marked improve¬
ment. Many cases of nervous syphilis, and especially tabes and paresis,
do not very well bear energetic treatment, and he much doubts the
wisdom of the dictum that the treatment should be continued until the
spinal fluid is normal.

In conclusion it may be remarked that, quite apart from the value of
the book as a record of a large and extensive experience, the essentially
practical manner in which the author has handled his material con¬
stitutes a strong claim for its usefulness to every practitioner who may
have to deal with problems of the diagnosis and treatment of syphilitic
diseases of the nervous system.

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Morbid Fears and Compulsions : Their Psychology and Psycho-analytic

Treatment. By H. W. Frink, M.D. London : Heinemann, 1918.

8vo. Pp. 568.

This book is prefaced by an introduction from the pen of Prof.
J. G. Putnam, of Harvard, who testifies to the abundant knowledge
and conscientiousness of the author, a New York physician already
known as closely associated with the American branch of the psycho¬
analytic movement. He is of the strictly Freudian school, making
little reference either to Adler or to Jung, but he is a follower in no
slavish sense, presenting the old doctrines in a fresh and personal way,
and while not seeking to explain them away where to some they seem
repellant, he yet puts them forward in a simple, straightforward, reason¬
able way likely to disarm many opponents.

There are, Dr. Frink remarks, three classes of readers to whom a
book on psycho-analysis may appeal: those who are entirely ignorant
of the subject; those who know something and wish to know more with
the probable intention of putting their knowledge into practice; and
those who know so much that they are only interested in questions of
technique and elaborate cases. It is to the second class of reader he
appeals, and it is for physicians who desire to take up psycho-analysis
in practice that his book will be chiefly valuable.

The book covers wider ground than its title may suggest—indeed, the
whole field of medical psycho-analysis. If, in accordance with Freudian
doctrine, we are concerned with sex interests in the largest sense (to avoid
the danger of unduly narrowing this sense of the word “sex” Frink pre¬
fers to call them “ holophilic ” interests), fear is to be regarded as either
the repressed wish or libido itself converted into another form, or, we
may better say, the protective reaction against the libido. It is the
embodiment of the prayer, “ Lead us not into temptation ”—the classic
prayer of him who is afraid of his own desires. The task before the
author is thus that of expounding all the chief primary Freudian
conceptions with special reference to the neuroses. Sometimes he
does this in Freud’s own words. More often he sets forth the doctrine
in his own way, showing a clear realisation of its significance and
illustrating it at every point by observations drawn from his own rich
experience. In further illustration he brings forward a detailed case
(over 100 pages) of compulsion neurosis and a shorter history of anxiety
hysteria. Throughout, the author shows his practical common-sense
attitude by confining himself to the essential features of a case, and
avoiding the fine-spun elaborations of interpretation which sometimes
fascinate the psycho-analyst and arouse the wrath of the sceptic.
Perhaps the most original feature of the book is an attempt to bring
the Freudian conception into harmony with the behaviouristic psy¬
chology, but the author modestly disclaims his competence to do more
than suggest this briefly.

Dr. Frink’s wide and thoughtful attitude is well exemplified by the
closing pages, in which he discusses some of the deeper implications
of psycho-analytic therapeutics. It is not, he remarks, mere “ knowing ”
or “understanding” which cures the patient; it is the living over again
of what has subsided from consciousness which has the therapeutic

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effect. Just what this consists in, or why it should have this beneficial
effect, remains, it seems to the author, decidedly obscure; we can
hardly even guess. It is clear, however, that psycho-analysis is a
re-education, and in the fullest sense, not, as so often education is,
a process of repression—a Procrustes’ bed to which the child is forcibly
fitted—but a real leading out of the energies along the lines that give
them fullest and most advantageous expression. In the re-education
of psycho-analysis this false education has often to be undone; the
resistances dissolved by the analysis are in part those instilled by a
supposed moral training. Thus, in a sense, psycho-analysis tends to
destroy morality, but it is a false morality which is thus destroyed, and
“ the result of overcoming certain moral inhibitions may really be the
attainment of a higher degree of morality than was possible while they
were in force.” The conscience is re-formed into a shape that furthers
the welfare of the individual and increases his adaptation to life. That
the process is not easy and that much circumspection is needed to
avoid danger the author readily admits.

It may be noted that the death of Prof. Putnam, who wrote the
introduction to Dr. Frink’s book, had already occurred before the
publication of this English edition. His final appearance here was
characteristic of the man, for he had always been a pioneer, and among
the older generation he was the most distinguished who came forward
in America at an early stage as an avowed supporter of Freud, though
his support was given in a judicial and discriminating spirit, as is clear
even from this introduction. He died leaving behind him, Prof. Lowell
has said, the reputation, not only of a physician of the highest attain¬
ments, but of “ philosopher and saint.”

Havelock Ellis.

How to Enlighten our Children. By Mary Scharlieb, M.D., M.S.

London : Williams & Norgate.

Dr. Scharlieb maintains that it is the duty of parents to prepare their
children for the part they have to play in life, but, through ignorance or
diffidence, this is too often neglected. The young man or woman is
left uninformed of sexual hygiene, often with injurious results.

This book, which is written for parents, presents the necessary
information and tells how and when the knowledge should be
imparted.

The changes in the structure and functions of the body and the
mental and moral outlook in puberty and adolescence are described in
simple language. It is pointed out how necessary it is, at these
transition periods, for a mother to explain what these changes mean and
how essential it is for her to help her daughter to look after the general
health by proper feeding, recreation, clothing, etc.

In the chapter on reproduction valuable advice is given on imparting
the information to the child. This is led up to by a description of the
reproduction processes in plants and animals.

Dr. Scharlieb considers that the parents should be frank and open in
communicating these facts, and she believes that, if the child is asked to

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treat them as confidential, the desire to guard the secret will overcome
the natural inclination to speak of it to others.

A chapter is devoted to specific diseases, to the means of infection
and their results.

The book, which deals with a difficult subject, is full of valuable
information and is written in a simple manner. It is one which should
be in the hands of all parents and guardians of young people.

Advaticed Suggestion ( Neuro-induction ). By Haydn Brown, L.R.C.P.

Edin. London: Bailliere, Tindall & Cox, 1918. Pp. 342.

That suggestion is a valuable method of treatment which is not made
use of in as many cases as it should be is slowly being recognised.
This seems to be borne out by the very large number of books on the
subject which have appeared recently.

The “ technique ” which Haydn Brown employs, but which is not
described, is referred to as being of a simple character.

Hypnotic suggestion is not recommended because the will-power of
the patient is merely in a state of obedience, while by neuro-induction
the will-power is steadily increased. The author states that the best
results are obtained only with the co-operation of the patient in this
method of treatment. He maintains that the sexual factor in mental
disorders is not nearly so important as Freud believes, and he advises
that the word, association test should not be adopted in the diagnosis or
treatment of these conditions.

Reference is made to a very large number of clinical cases treated by
Haydn Brown. In many of them excellent results would be expected,
but there are others, both medical and surgical, in which the cures must
be considered remarkable.

It is unfortunate that so many new terms are introduced into the
book as they tend to lead to confusion. The omission of a description
of the technique employed considerably detracts from the value of
the book as a practical guide to treatment. Curiously works of this
nature frequently suffer from this defect.

Part III.— Epitome of Current Literature.

1. Psychopathology.

Shakespeare's “ Othello ” as a Study of the Morbid Psychology of Sex.
(.Nineteenth Century , June , 1919.) Sullivan , IV. C.

Othello has usually been viewed as a tragedy of heroic love rather
than as a tragedy of insane passion, which the writer contends is
probably the correct interpretation. Definite indications are afforded
in the play of the pathological temperament of Othello, and it is
suggested that Iago, who is depicted by Shakespeare as inhumanly

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wicked and supreme in evil, is used in the play as the dramatic repre¬
sentation of morbid passion. He is not an actual human personage,
but he represents the projection of the insane thoughts and impulses of
Othello; he is the dramatic device for showing the growth of diseased
passion in the mind. The gross sexual imagery in the speeches of Iago
are those which express the condition of a jealous lunatic. Just as
Hamlet’s hatred is crystallised by the confirming voice of the Ghost,
and the subconscious stirring of ambitions in the soul of Macbeth are
dramatically presented in the prophecies of the witches, so the growth
of morbid jealousy in Othello expresses itself in gross sexual thoughts
of hallucinatory intensity projected into the inhuman figure of Iago.

H. Devine.

2. Clinical Psychiatry.

General Paralysis among the Jews [Die Paralyse der Juden in
Sexuologischer Beleuchtung ]. (Zt. f. Sexualwiss., June , 1919.)
Sichel, M.

Until recent times general paralysis has been rare among Jews.
Then it rapidly increased until it affected a fifth of the Jewish inmates
of asylums. In the last decade this proportion has slightly fallen, but
the fall appears to be apparent rather than real, as Sichel here explains.

What are the causes of this sudden development of general paralysis
among Jews ? Zollschen believes that syphilis works more virulently on
Jews because they were previously so free from it. Sichel finds diffi¬
culties in this explanation, and attaches more importance to the growth
of large cities and the confinement of Jews in such cities, with the
manifold opportunities for sexual excesses thus opened to them. In
nearly all large cities there is a special prevalence of general paralysis
among Jews as compared with the general population. Sichel quotes
figures for Vienna, London, and Frankfort. In rural districts, on the
other hand, general paralysis is extremely rare among Jews. The
spread of the disease is evidently dependent on urban life, and it is
suggested that the results of the war, which have led to the cry of “Back
to the plough ! ” even among Jews, will in this respect be beneficial.

The author remarks that his thesis concerning the connection
between the Jewish attraction to urban life and the special prevalence
of general paralysis may seem to be shaken by what is witnessed in
Russia. There the Jews are exclusively town-dwellers, for they had not
been allowed to be anything else, yet general paralysis is very rare
amongst them. This Sichel attributes to the thorough manner in
which the eastern Jews still exercise their traditional rites and customs.
The unfavourable political conditions which have led to their doing
this have been one of those forces which “ willed evil and produced
good.” The eastern Jews have been enabled to retain their vital
energy uncontaminated, and as we pass from east to west we find an
ever-decreasing neglect of traditional observances, and, concomitantly,
an ever-increasing prevalence of general paralysis.

This result has, however, been powerfully aided by the custom of
early marriage among the eastern Jews—a custom which has decayed in

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the west owing to the increasing difficulties of living. We may expect
that, in this respect also, the war will be influential. The care with
which Jewish families surround young girls has been largely maintained
in the west, and that is probably the reason why the prevalence of
general paralysis is only among men, Jewish women being remarkably
free from it.

A further factor is found in the increasing abuse of alcohol among
the Jews, who formerly tended to be abstemious. Sichel finds that in
his own observations 17 out of 127 Jewish general paralytics had
had alcoholic tendencies, though the abuse of alcohol had been rare
among some 840 other Jewish asylum inmates; “there is a certain
connection between alcohol and general paralysis.”

It is also noted that Jewish general paralytics in the great majority
belong to the commercial class, and in their daily life had many oppor¬
tunities for acquiring syphilis. Of late, however, it is found that
general paralysis is extending to other Jewish social circles, and that it
is no longer rare among artisans. Havelock Ellis.

A Proposed New Classification. (The Mechanistic Classification of
Neuroses and Psychoses produced by Distortion of Autonomic
Pufictions). {fiourn. Nerv. and Merit. Dis., August, 1919.)

Kemffi E. J.

The author, who is Clinical Psychiatrist at St. Elizabeth’s Hospital,
Washington, here proposes a new classification of the psychoses and
neuroses based on the view that “ the same forces which build up a
personality when harmoniously integrated cause its deterioration when
unadjustable conflicts occur.” Modern psychiatry, he believes, needs
an elastic adaptable hypothesis,a direct terminology, a simple comprehen¬
sive method of classifying cases. The Kraepelinian system fails because
it is fundamentally on a static basis, emphasising symptoms and
prognosis. Symptoms are grouped into circumscribed entities of
disease, despite the fact that in a large proportion of cases the sym¬
ptoms are classifiable into two, three, or even more groups, such as
neurasthenia, manic-depressive or dementia praecox types, while about
half the cases are, at one period or other, atypical. There is thus
nothing to do but dogmatically to force the most suitable diagnostic
term on to the case for statistical purposes.

It seems to Dr. Kempf, therefore, more practical to classify psycho¬
paths according to the nature of their autonomic-affective difficulties
and their attitude towards them, because this keeps the dynamic
factors directly in psychiatric attention and permits of revision as the
symptoms change. The system of terminology here proposed relates
to the essential mechanistic factors that make a case curable or incurable,
and an important distinction is made between benign and pernicious.
“Benign” means that there is “a tendency to accept the personal
source of the wishes or cravings which cause the distress or psychosis ”;
“ pernicious ” means that there is a tendency to refuse to accept the
personal source of the wish or craving, to hate those who attribute a
personal source, and to blame some external or impersonal source.

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CLINICAL PSYCHIATRY.

There are five groups in the system: (i) Suppression neuroses , with
clear to vague consciousness of the ungratifiable nature of the affective
cravings, and distressing hyper-tensions or hypo-tensions of autonomic
(visceral) segments. (2) Repression neuroses, with vague to total uncon¬
sciousness of the nature of the influence, and the symptoms of the first
group, augmented by functional distortion of the projecting apparatus
and changed reactivity to sense-organs. (3) Compensatory neuroses, with
persistent striving to develop power and control and win esteem due to
the fear of losing them, usually accompanied by some of the same
symptoms found in the previous groups, with additional compulsions
and inspirations to strive for favourable conditions, resulting in all sorts
of eccentric attitudes, and on the physical side increased muscular
tension, high blood-pressure, tachycardia, exophthalmic tension, hyper¬
active thyroid, adrenals, etc., glycosuria. These three groups are
benign ; the next two are pernicious. (4) Regression neuroses, with
failure to compensate, but return to an earlier more comfortable irre¬
sponsible level, permitting wish fulfilling fancies, postures, and indul¬
gences—together with persistence of attitudes belonging to the child
stage and general inefficiency and depression. Lastly (5) Dissociation
neuroses, where uncontrollable cravings dominate the personality and
there are distressing visceral tensions and all kinds of sensory and
social derangements.

The author fits the old diagnostic terms into this new framework in
ways that can usually be guessed, but the commonest of the current
types—manic-depression, dementia prsecox, hysteria, etc.—fall into two
or more of the groups. It will be seen that the term “ psychosis ” is
dropped altogether, on the ground that “ the sensory phenomena which
we are conscious of as thoughts and wishes are the result of integrative
physiological processes, and the term ‘ neurosis ’ is more consistent
with the integrative functions of the nervous system.” No reference is
made to the psycho-analytic school of thought, or to the work of
Sherrington, Cannon, and Crile, but the inspiration of this classification
is sufficiently obvious. The author observes that it is only to be
considered “experimental and suggestive,” but he has himself found it
useful. Havelock Ellis.

Concerning “ Constitutional Coencesthopaths ” [A proposito di “ Cenesto-
patici Constkuzio?iaIi , '‘\ (Arch, di Anthrop. Criminale, vol. xxxix,
fasc. 3-4, 1918-1919.) Lattes Leone.

The term “ constitutional coentesthopathy ” was suggested by Prof.
Buscaino (Revista di Rato/. Nerv. e Metitale, 1918), as a useful de¬
nomination for a group of symptoms of emotional origin met with in
patients who came under his observation in military practice, especially
in connection with acts of misconduct—desertion, insubordination,
impulsive assaults, attempts at suicide and self-mutilation. Buscaino
observed that the majority of these individuals complained cf anomalous
sensations referred to the viscera, and that they also presented objective
signs of disordered functioning of the sympathetic system, notably
exaggerated reaction of the pulse to change of position, and disturbances
of the oculo-cardiac reflex. In the present paper Lattes, while not

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disputing the facts adduced by Buscaino, criticises, from the medico¬
legal point of view, his conception of constitutional ccenjesthopathy on
the ground that the disorders referred to are of frequent occurrence in
moral defectives and congenital criminals, and that in fact the military
offenders presenting these symptoms belong for the most part to the
category of the instinctive delinquent, and should not, therefore, be
allowed to escape the penal consequences of their acts on the plea of
being the subjects of nervous disease.

The point appears of rather academic interest except as illustrating
the greater prominence which the experience of the war has given to
the problem of the neurotic and border-line criminal.

VV. C. Sullivan.

Dream-state due to Acute Exhaustion , with Psycho-analytic Note
[Stato Sognanie vero da esaurimento Acuto, con indagine Psico-
Analitica\. (Arch, di Anthrop. Criminale , vol. xxxix, fasc. 3-4,
1918-1919.) Marro, Giovanni.

This paper is a detailed report of a rather remarkable case of oniric
delirium. The patient, a man, aet. 32, was an Austrian official, lodging
with an Italian family in Alessandria, and subject as an alien enemy
to the usual measures of supervision.

On February 18th, 1916, as the result of a prolonged bout of sexual
excess, he got into a condition of pronounced nervous exhaustion with
rise of temperature, profuse sweatings, and absolute inability to take
food. These symptoms continued till February 25th, when he suddenly
got up, left his lodgings, and made his way to Turin, where he engaged
rooms and reported himself to the police authorities, telling a circum¬
stantial story to the effect that he had killed two persons at Alessandria
who had attempted his life for motives of vengeance because he defeated
their projects of usurious exploitation, that the judicial inquiry had
exonerated him on the ground that he had acted in self-defence, but he
had been advised to leave the town. The Turin officials telephoned to
Alessandria, and found that no such incidents had occurred, and the
patient was accordingly, in spite of his vehement protests, sent to the
asylum for observation. There he maintained the truth of his story,
and asserted further that shortly after his admission to the asylum he
was visited by his parents, who were enabled to come to see him because
peace had been made between Austria and Italy. In three days his
temperature fell to normal, the sweatings ceased, and he became more
reconciled to his detention. And after two days more he suddenly
announced that he had dreamt the whole affair.

At Marro’s request the patient wrote out a minute account of his
imaginary experiences, and from this document, supplemented by the
results of interrogation, it was established that the fantasies arose in a
series of connected dreams beginning on February 24th, and having
their apparent starting-point in a proposal, really made to him on that
date, to advance him a sum of money. Marro’s analysis satisfied him
of the existence of a painful emotional state due to the patient’s
unpleasant position as an alien enemy, to his financial difficulties, and
to his self-reproaches at being obliged to be a non-combatant at a

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1920.]

moment of crisis for his country. The imagined acts of violence
symbolised his repressed wishes to fill a more bellicose role , and were
associated also with a disagreeable and very lively memory of youthful
indiscretions with moneylenders. W. C. Sullivan.

3. Pathology of Insanity.

The Pathogenesis of Chronic Alcoholism \Sobra la pathogenesis de la
intoxicacion alcoholica ]. (Rev. de Criminol ., Psiquiatria, y Med.
legale , Anno V, No. 26, 1918; reference in Arch, di Anthrop.
Criminate, vol. xxxix, fasc. 3-4, 1918.) Ducceschi and Pari lari.

From a clinical study of 121 subjects, including abstainers as controls,
and from a series of experimental researches, the authors state that
continued intoxication with ethylic alcohol in man and in animals
determines a manifest increase of cholesterin in the blood, which in
their view explains the generalised organic lesions met with in chronic
alcoholism. VV. C. Sullivan.

The Blood Urea Nitrogen in Katatonia. (yourn. Nerv. andMent. Pis.,
February , 19x9.) Rappleye, IV. C.

Examinations of the blood were made before, during and after
semi-stuporose phases of katatonia. The cases chosen were mild ones
who ate during the period of examination, and the blood was taken
before breakfast, about twelve hours after a previous meal, so that the
food factor was eliminated as far as possible. Controls were carried
out on other patients having similar diet, and the efficiency of the
renal function was ascertained in every case. The blood urea nitrogen
values showed a 50 per cent, or more drop from normal during the
semi-stuporose katatonic phase. The significance of this finding is
considered as probably due to lowered endogenous metabolism with
vasomotor hypotonia. Renal stimulation and incomplete protein
absorption from the intestines are considered as unlikely causative or
associated factors. F. E. Stokes.

4. Treatment of Insanity.

Modified Psycho-analysis in Borderland Neuroses and Psychoses.

(Psycho-anaf. Rev., yuly, 1919.) Clark, Pierce.

For some seven years the author has made use of psycho-analytic
methods in borderland cases. He here briefly summarises results
which will later be set forth in full detail.

Seven manic-depressive cases came under consideration. In all it was
found advantageous to go carefully over the conscious and foreconscious
settings of the patient’s difficulties, especially those which seemed to
precipitate the periodic depressions. Dream production was mostly
found to have quite adult settings and not even latently sexual in
interpretation. Nor could analysis be pushed rapidly or completely
as in the hysteric neuroses, but dream interpretations had to be, as it
were, distilled. These periodic depressants seemed to demand mostly a

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common-sense re-formulation of their attitudes towards life-problems as
embodied in the marriage situations, with sublimation and substitution
for those not married. A psycho analytic understanding of the patient’s
emotional life greatly helped this task. These patients exhibited but
little grit, courage, and perseverance, or hold on the basic realities
of life.

A similar essential weakness of the primary instincts of life was
revealed by “ mental torticollitics,” the individuals possessing an
intensely infantile emotional life with intellectual endowments below
those found in compulsion neuroses. The inversion required by psycho¬
analysis reduced them to impotence, and they had to be assisted towards
new developmental principles needed for adulthood.

Dementia praecox is usually seen too late for helpful psycho-analysis.
In such cases any pure application of it, the author believes, invariably
does harm. It takes away the crutches the patient has made and
reduces him to impotence. He should not be analysed, but receive
conscious suggestive therapeutics.

In conclusion, the author states, psychoanalytic methods should
only be used in borderline neuroses and psychoses with the greatest
care, but may be employed freely by the physician to enlighten his own
mind on the problems of the case he has to meet.

Havelock Ellis.

5. Sociology.

Sex Expression on a Lowered Nutritional Level. {Journ. Nerv. and
Ment. Eis., March , 1919.) Afiles, IV. R.

There appear to have been so far only fragmentary data in existence
concerning the effects of under-nutrition on the sexual impulse. Some
interest, therefore, both theoretical and practical, attaches to a study of
the effects of prolonged restriction on diet lately carried out at the Nutri¬
tion Laboratory of the Carnegie Institution in Boston. The inquiry into
sex effects was a by-product of the investigation, and it is believed that
the influence of suggestion may be for the most part excluded.

Two squads of students, all young men and one married (“a clean
group of honest, virile fellows, with no venereal disease”), were selected,
twelve in each squad, the second squad being for control purposes, and
put under a restricted diet, approximately two-thirds to one-half of their
supposed caloric requirements, during a period of four months. The
main results were a reduction in basal metabolism of 18 per cent, per
kilogramme of body-weight, lowered blood-pressure, and a drop in pulse-
rates but not in temperature. There was little decrease in neuro muscular
co-ordination, no falling off in scholastic work, very little in physical
strength, and no apparent lack of vitality or efficiency or athletic vigour.

A few days after the termination of the experiment the inquiries
regarding sex phenomena were made of each man privately and indi¬
vidually. There had been no preliminary reference to this subject, but
the men w’ere all willing to discuss the matter freely and fully. They
were warned of the possibility of fallacies due to suggestion or intro¬
spection. Their evidence gave the impression of truth.

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SOCIOLOGY.

Out of 23 of the students of whom the inquiry was made, 22 reported
a decreased general sex interest, the remaining 1 stating that there was
no change; 16 out of 22 stated that there was a decrease in the number
of nocturnal emissions, 6 observing no change, and none noting any
increase; 13 had observed a diminished frequency of erections, 4
observing no change in this respect; 9 found the desire for association
with the opposite sex diminished; several reported that the sex appeals
of dances, social occasions, picture shows, stories, etc., were diminished ;
the married man, it may be noted, used the term “unsexed”to describe
the effect of the low diet on himself. At the time of the inquiry, about a
week after the end of the experiment, many were already experiencing
a return of normal sex desires and activities under an unrestricted
diet.

Miles remarks that these results confirm the supposed connection
between sex and metabolism and agree with the results reached by
Riddle and others, who, studying the lower animals, find that sexual
activity is probably dependent on the metabolic level. Nature appears
to require a high metabolic level for purposes of race propagation.

The author remarks in conclusion that the results also clearly indicate
a method of treatment for achieving restraint of sexual tendencies in
pathological cases of excess. Havei.ock Ellis.

The Berlin Institute of the Sexual Sciences [Der Institut fur Sexual-
wissenschaften in Ber/in\. ( Zt. f. Sexualwiss ., August, 1919.)
Birnbaum, K.

Dr. Birnbaum here describes the aims and constitution of this
institution, founded by the generous efforts of Dr. Magnus Hirschfeld,
and opened last July in a building that was formerly the residence of
Prince von Hatzfeldt and previously of the famous musician Joachim.
(A later and longer account of the Institute appears in the fahrbuch fiir
Sexuelle Zwischenslufen, Bd. xix, Heft 1 and 2). It is the first
institute of the kind to be established anywhere in the world. Its
functions are double—in the first place for investigation, and in the
second place for treatment and clinical teaching. As an institute for in¬
vestigation there are four departments : (1) Sexual biology, dealing with
such questions as the chemistry of the endocrinic glands, heredi'y, etc.;
(2) sexual pathology, dealing with variations, etc., closely in touch with
the practical medical side of the Institute and possessing a museum which
is already rich in varied material; (3) sexual sociology, for dealing with
the relations between sex and society, eugenics, marriage, prostitution,
sexual hygiene, etc. ; (4) sexual ethnology, including the manners and
customs of different ages and peoples, and the influence of sexuality on
civilisation. The practical medical side of the Institute is also divided
into four departments : (1) For giving advice to those about to marry
or to choose a profession ; (2) a psychopa.hic department; (3) a depart¬
ment for psychic sexual troubles, as of potency, etc.; (41 disorders of
the genital organs. There are also a laboratory for analyses, and instal¬
ments for psychotherapy, organotherapy, electrotherapy, photography,
etc.

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In his inaugural address Hirschfeld spoke of the Institute as “a child
of the Revolution,” and destined to aid in the restoration of the place
which was “ lost through fatal errors inside and outside of the frontiers
of the country.” The Institute is already at work with clinical demonstra¬
tions to medical men every week, courses of lectures on forensic
sexology and on Freudian psycho-analysis, and frequent scientific lectures
to the general public. It is stated that over 500 physicians from
Germany and abroad have already visited the Institute. It is not a
State-supported institution, but the belief is expressed that it will not be
the less successful on that account. Havelock Ellis.

Part IV.—Notes and News.

MEDICO-PSYCHOLOGICAL ASSOCIATION OF GREAT BRITAIN

AND IRELAND.

The Quarterly Meeting of the Association was held in the Rooms of the
Medical Society of London on Tuesday, November 25th, 1919, Dr. Bedford
Pierce (President) in the chair.

The following signed their names in the book as having been present at the
meeting or as having attended meetings of committees : Drs. M. A. Archdale, Sir
Robert Armstrong-Jones, W. H. Bailey, W. R. Barkas, J. J. G. Blandford, C. H.
Bond, David Bower, A. Helen Boyle, James Chambers, G. Clarke, R. H. Cole,
Maurice Craig, J. Harvey Cuthbert, A. Daniel, H. Devine, J. Francis Dixon, R.
Eager, J. H. Earls, F. H. Edwards, Samuel C. Elgee, A. E. Evans, C. W. Ewing,
E. L. Forward, Claude F. Fothergill, S. G. Gilfillan, T. S. Good, W. J. H. Haslett,
H. E. Haynes, S. J. Irwin, G. H. Johnston, J. H. Kidd, H. Wolseley Lewis, E. S.
Littlejohn, J. R. Lord, H. C. Macbryan, H. D. MacPhail, W. F. Menzies, Alfred
Miller, F. W. Mott, Alex. W. Neill, David Ogilvy, E. S. Pasmore, George E.
Peachell, Bedford Pierce, J. E. Porter Phillips, Nathan Raw, J. M. Rutherford,
G. H. Savage, G. E. Shuttleworth, J. H. Skeen, G. W. Smith, T. W. Smith, J. G-
Soutar, P. Spark, R. ”H. Steen, R. C. Stewart, James Stewart, D. G. Thomson,
John V. Tighe, A. H. Trevor, C. Molesworth Tuke, L. R. Whitwell, C. E. C.
Williams, and Reginald Worth.

Visitors: Miss Branch, I. N. Kilner, F. W. Thurnman.

Present at Council Meeting: Drs. David Bower, A. Helen Boyle, James
Chambers, R. H. Cole, Maurice Craig, A. W. Daniel, R. Eager, H. Wolseley
Lewis, John R. Lord, W. F. Menzies, Alfred Miller, G. E. Shuttleworth, J. H.
Skeen, R. H. Steen, and D. G. Thomson.

Apologies for unavoidable absence were received from—Drs. Stewart Adair,
G. E. Auden, Aveline, Fletcher Beach, Col. Keay, Douglas McRae, Robertson,
Donald Ross.

The President said, in reference to the question of the confirmation of the
minutes of the last meeting, that they were in print, but the Journal containing
them would not yet have reached the hands of members. He therefore suggested
that, in case anything should aris.e concerning them, they be left until the next
meeting.

Report on Deputation to Ministry of Health.

The President said he had been asked by the Council to say a word on this
subject. The deputation from the Association to the Minister was a strong one,
consisting of officers of the Association, the Chairman and Secretary of the
Parliamentary Committee, Dr. Helen Boyle and Dr. Percy Smith, and altogether
it was thoroughly representative of the Association. They were very kindly

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NOTES AND NEWS.

received by Dr. Addison, the Minister of Health, who was supported by Sir
George Newman, Sir Robert Morant, and by Dr. Maurice Craig, Adviser to
the Board. The deputation presented the resolution which was approved by the
Annual Meeting of the Association at York, and, following it, a very interesting
and confidential discussion took place. But they found at the outset—which was
news to them at the time—that it was the intention of the Ministry of Health,
directly Parliament opened, to place on the table of the House of Commons a
petition for an Order in Council which would transfer the Department of the
Government under which the Board of Control acts from the Home Secretary to
the Ministry of Health. It was the intention that this Order in Council should be
obtained at the earliest possible moment. Had the Council of the Association
known of this intention beforehand, he thought that in all probability the resolution
would not have been required, nor would it have been submitted to the Annual
Meeting, because that was the main burden of the resolution—that the control of
lunacy administration, the control of mental defectives and of borderline cases
should all be under the Ministry of Health. It was a pleasant surprise to find that
the main object of the deputation had already been attained. Thus there remained
little more for him to report to this meeting, except that a frank discussion ensued
on various points arising in the consideration of this matter. And though the
Health Minister could not give a definite answer to the questions put to him, their
reception was very kindly, and the members of the deputation felt they had had a
useful opportunity of discussing the problems of lunacy administration.

Items from the Council Meeting.

There were several questions discussed at the Council Meeting just held which
it was desirable to mention. The first was, that he was pleased to say Sir James
Crichton-Browne had consented to deliver the first Maudsley Lecture under the
Maudsley Bequest. It was proposed that this lecture should be delivered at the
time of the Association's meeting in May.

The question of the Editors of the Journal was also discussed. It was the
intention that in future there should be four Editors : Lieut.-Col. J. R. Lord, Dr. H.
Devine, Dr. G. Douglas McRae, and Lieut.-Col. W. R. Dawson. The Council
had approved of that course, and unless this meeting should express anything to
the contrary those names would be printed on the front page of the Journal as
Editors in future. He felt sure there would be a conviction that the Journal would
be well conducted at their hands.

The Council also felt that the position in regard to the registration of nurses was
becoming a very serious one. They had been informed there was every possibility
that there would be a Supplementary Register for mental nurses, and there was
every possibility that the examination conducted by this Association would be
recognised as a means of registration. If this should be carried out by the Ministry
of Health, he thought it would be most satisfactory. The question was also raised
as to whether it would not be important that, somehow, it should be arranged for
mental nurses to be nominated on the Advisory Council of the new Bill. They
knew of no machinery for the appointment of such nursing members, and it was-
decided to endeavour to arrange, through the Asylum Workers’ Association, that
two names of their members should be submitted—a male nurse and a female
nurse—and it was thought that the best way to arrange this would be that all
asylums and other institutions in which qualified mental nurses were now working
should receive a circular from this Association, asking them to call meetings
immediately of registered nurses in their respective institutions, and, if possible,
that these meetings should approve of the nominees of the Asylum Workers’
Association. It seemed extremely important that no time should be lost, otherwise
there was a danger that mental nurses would not be represented, as such, on the
governing body of the new Bill. He did not know whether any member of the
Association would like to make observations on this matter.

Lieut.-Col. D. G. Thomson asked why the Asylum Workers’ Association was
brought into this matter at all. They had great respect for that body, but it was
now practically moribund.

Dr. Soutar said he believed the answer to the remark of Col. Thomson was that
the representative of the nurses must be nominated by an organised body ; that

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was a condition laid down. No organised body of mental nurses generally was in
existence except the Asylum Workers' Association, which, though dying, was not
yet dead. And it was thought that at all events this final effort should be made to
secure the nomination of nurses for the Council under the Bill. If that were
accepted by the nurses throughout the country, then an organised body would
have nominated four members to the proposed Council.

The President said it would be a recommendation to the Minister of Health,
for that Ministry would make the appointment, and this would come merely as a ^
suggestion to that Minister, putting forward the machinery through which suitable
names could be submitted.

Dr. Soutar further remarked that this Association would be represented on that
Council, and names would be submitted.

Dr. ELGEEsaid he thought many mental nurses would not be represented by the
Asylum Workers’ Association.

Dr. Edwards said he did not know whether the Council had information about
the presentation of the new Bill. He believed the Registration of Nurses Bill
came up before the Summer Session and was rejected. It was now desirable that
these meetings should he held as quickly as possible all over the country, because
when a Bill had once been launched it was very difficult to get amendments incor¬
porated.

The President said the steps being taken by the Association had the full
approval of Col. Nathan Raw, M.P., and he would give them all the support he
could. The question was asked whether this Association was to be represented on
the new Council, and he had been honoured, as President of the Association, by
being asked to let his name be submitted to the Minister, so that, subject to the
Minister’s approval, it might be one of five names put forward.

Dr. Bower and Dr. Soutar insisted that the President’s name was suggested
for personal reasons, not because he happened to be President this year.

The President said the Council had asked him to refer to yet another matter,
namely, the desirability of awakening interest in the Association on the part of
medical men throughout the country to the important work which this Association
was doing. It had been decided to prepare, in the course of a few weeks, a memo¬
randum, which would be sent round very widely, suggesting that assistant medical
officers and medical men associated with pension boards and with the neurological
department of hospitals should be invited to join the Association, or if they had
once belonged to it to rejoin it now that the war was over and the Association’s
activities were recommencing in a more vigorous fashion.

Obituary.

The President said it was his sad duty to refer to the death of three valuable
members of the Association.

In the first place he would mention the death of one of the Editors of the
Journal, Dr. Drapes. He had been an exceedingly valuable and active member,
and he had set all a wonderful example of regular attendance, as he came frequently
from the south of Ireland to attend the meetings, and he had done an immense
amount of unseen work in helping forward the Association, both as regards the
Journal and the Education Committee. He was present at the last Annual
Meeting of the Association, taking an active part in the proceedings and partici¬
pating in all the proceedings, and he (the President) had received a letter from
Dr. Drapes afterwards, in which he spoke very warmly of the happy time he had
in York. He believed it was correct to say that Dr. Drapes caught a chill while
he was actually engaged in the work of the Association and the Journal, and after
two or three days of illness he died of pneumonia. He was sure all members
would greatly deplore his loss.

The next death he had to refer to was that of their illustrious member, Dr.
Mercier. All the time that he (Dr. Pierce) had been a member of this Association
Dr. Mercier had been one of its foremost and most active members. He had been
President, and for nineteen years he was closely associated with the Education
Committee, first as Secretary, afterwards as Chairman. He believed Dr. Mercier
was the first person who wrote a book on the subject of nursing the insane, and he

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helped in the compilation of some of the early editions of the Association’s Hand¬
book. Throughout his life he took a deep interest in the question of nursing.
It was on this account that he (the speaker) asked Dr. Mercier to give one of the
opening lectures at “The Retreat" to the nurses there, and he delivered an
address which was really a masterpiece of exposition on the principles required in
nursing mental cases. That address had since been published, and he hoped
members had read it. It dealt not only with mental nursing, but with the principles
required for all who were attending on the sick. A man who had written so much
had left behind him such vivid testimonies of his worth and character that any
remarks which a friend or disciple could make were, perhaps, of small moment.
Yet there were two particular features of Dr. Mercier’s life to which he would like
to make brief reference. The first was his capacity for taking pains and his perse¬
verance. It was a surprise to him (the speaker), and perhaps to others, also, that
Dr. Mercier commenced life in a very hard school. He left school life quite early
and went to sea. Afterwards he was a warehouseman in the City. Though in
straitened circumstances he contrived to join the London Hospital, and when he
reached his twenty-sixth year he was a Fellow of the College of Surgeons. He had
a distinguished career and became an eminent man. Those who were familiar
with his writings—and all the members of this Association were familiar with
them—might have supposed it was an easy matter for him to write, but Dr. Pierce
had a letter from him, from which he would like to read to the meeting an extract :
“ Writing, as Clifford Allbutt calls it, is the supreme art. The only way to write
is incessant and careful practice and everlasting revision. I have written my book
on Logic already about seven times, and am now again beginning Chapter II, and,
of course, all the succeeding chapters must be once more re-written. But, of
course, the subject is one of exceptional difficulty.” That book on logic had now
been published, and though the -professors on that subject possibly did not give it
the reception which Dr. Mercier expected them to, yet he thought it would stand
the test of time.

The other outstanding attribute of Mercier’s life was his fortitude. It was known
to many members that Mercier was obliged to give up active medical work on
account of a progressive, painful and exhausting illness. It was at about this time
that he gave the lecture to the nurses of "The Retreat," to which reference had
already been made, and at about that date Dr. Mercier wrote to him a very sad
letter, in which he said, " I am no better in health, and never shall be ; I get worse,
week by week, and long for a release from a life of misery.” This was not just the
remark of a person in a moment of depression. It was wrung from a man racked
with bodily suffering. When Dr. Mercier gave this lecture he could scarcely stand
during the hour that it occupied, and he (the speaker) knew how much the lecturer
suffered while he was giving it. He received a letter from Mercier's devoted sister
after the former’s return from York, in which she wrote, " I am sorry to say the
inevitable reaction has set in; to-day he is prostrate with fatigue and complains of
faintness ; but his life, at best, is such a sad one nowadays that I cannot think that
the pleasure which these little outings give him is too dearly bought. He has so
little to enjoy, and as he sometimes has these fits of prostration and languor without
any apparent reason I think it is wise to keep going while he can, even at the price.”
And Dr. Mercier did “ keep going ” for another ten years, and he was sure mankind
had been the richer for his fortitude. Perhaps there was no need to say more than
to conclude by readingthe last sentence of his address to the York nurses: “ Not to
everyone is it given to govern empires, to explore unknown lands, to discover the
secrets of Nature, to enrich nations by some great invention ; but we can all do well
and truly the work which lies to our hands ; we can all contribute to make the lives
of those around us happier and better ; we can all live so that at the inevitable hour
when we have to bid farewell to this earthly scene, many will sorrow for our loss,
and we can feel, with thankfulness, that the world is even a little happier because
we have lived, even a little better for our example.” We mourn his loss.

And the third death he had to refer to was, perhaps, even sadder, namely, that
of Dr. Fearnsides, for he was cut off in the midst of an active life at the full
measure of his strength. A neurologist of great power, he died as the result of a
boating accident. Members deeply sorrowed at his loss, and grieved that he could
no longer carry on the great work in this world which he was undertaking.

It would, he felt sure, be the wish of members to express their sympathy with

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the surviving relatives of their departed members, and he asked that this be
approved by standing.

The resolution was carried by members rising in their places.

Election of Candidates for Membership.

The following were elected :

Branthwaite, Robert Welsh, C.B., M.D.Brux., M.R.C.S., L.R.C.P.,
D.P. H.Lond., Commissioner of the Board of Control, 66, Victoria Street,
London, S.W.

Proposed by Drs. Sidney Coupland, C. Hubert Bond and Arthur
Rotherham.

Blakiston, Frederick Cairns, M.R.C.S., L.R.C.P., Medical Superintendent,
Isle of Man Asylum.

Proposed by Drs. Edwyn H. Beresford, P. M. Turnbull and R. Worth.

Johnston, Millicent Hamilton, B.A., M.B., B.Ch., T.C.D.. Assistant
Medical Officer, Brentwood Mental Hospital.

Proposed by Drs. J. Turner, J. Noel Sergeant and Adele I. de Steiger.

Westrup, Joseph Percival, M.R.C.S.Eng., L.R.C.P.Lond., M.O. Fisherton
House Mental Hospital, Salisbury.

Proposed by Drs. H. Kerr, H. Devine and T. C. Shaw.

Wheeler, Frederick F., M.R.C.S., L.R.C.P., Assistant Medial Officer, Long
Grove Mental Hospital, Epsom, Surrey.

Proposed by Drs. D. Ogilvie, R. H. Cole and R. Worth.

Gifford, John, B.A., M.B., Ch.B., Senior Assistant Medical Officer, Derby
County Asylum, Mickleover.

Proposed by Drs. H. Devine, F. E. Stokes and R. Worth.

The scrutineers were Dr. Steen and Lieut.-Col. Lord.

The Association’s Finances.

Dr. Worth said that during the meeting at York a discussion arose on the
Treasurer’s Report, and it was decided that a special Sub-Committee should be
formed to consider the financial position and report to the Council. This Sub-
Committee consisted of Dr. Bedford Pierce, Dr. Chambers, Dr. Menzies and Dr.
Worth, and the Divisional Secretaries. After a good deal of discussion they
arrived at three decisions. The first was that the annual subscription should be
raised to one and a-half guineas, especially to meet the extra cost of producing the
Journal. Members would remember Dr. Drapes pointing out how high had been
this cost, and that endeavours would be made to procure other prices. There
were, however, objections to this course, and it was decided to approach Messrs.
Adlard with a view to getting some reduction in the cost of the printing,etc. Also,
it was considered that all medical superintendents should be approached with the
idea of extending the Association’s propaganda among medical officers, to encourage
them to, if possible, take more interest in the Association's activities. Indeed, it
was suggested that it should be an understood thing that every medical officer
appointed in an asylum should be a member of this Association. The last
suggestion was to encourage the sending in of ideas with regard to brightening
and improving the Journal.

Revision of the Mental Nurses’ Handbook.

The President said the Education Committee decided that the time had
arrived when the Handbook for mental nurses should be revised. They were
taking preliminary steps to appoint an Editing Committee. He mentioned the
matter now, so that when the time came members might be prepared with
suggestions. He hoped suggestions would be forthcoming, so that not only would
the Handbook be improved, but would be worthy of the Association.

He regretted that Major Shaw had been obliged to withdraw his paper, as the
India Office had not passed it.

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NOTES AND NEWS.

Paper.

Dr. Charles Hubert Bond (a member of the Board of Control) read the
following paper : " The Need for Schools of Psychiatry ” (vide p. 10.).

The President said members felt greatly indebted to Dr. Bond for giving this
admirable survey of the subject. There were several in the room who had served
on committees which had dealt with the subject. It was a great advantage to
have the points so clearly put forward, pointing the way for advance. They
realised the enormous number of military clinics which had been established had
created a new situation and now was the time for making a permanent improve¬
ment.

Lieut.-Col. Lord said the subject which Dr. Bond had just brought before the
Association was one of vast importance. He took it that the paper aimed at the
more thorough treatment of patients with a view to their cure. People suffering
from mental trouble were too frequently looked upon as a class apart from indi¬
viduals who suffered from ordinary bodily ailments. Such views should be
vigorously opposed. Lunacy was essentially a medical matter and not a social
disease, though, like all medical problems, it was important socially. Efforts
should be concentrated on curing mental disease, not merely reclassifying the
unfortunate patient in an isolated category of the scale of humanity. It was most
desirable that specialism with regard to the treatment of mental diseases should be
encouraged far more in the future than it had been in the past. He mentioned
that the war had taught the profession many things in this respect, and it was only
through the concentration of the best efforts and by special administration that
the immense progress in the cure of many diseases and injuries incidental to or
exacerbated by warfare had been effected. These methods could well be considered
in connection with mental diseases. The medical effort in psychiatry was too
wide-spread and diffuse, and resulted in too much general knowledge to the exclu¬
sion of special knowledge of particular groups of mental disorders. It could not be
helped at present, but until this was remedied no real progress could be made.
There seemed to be no reason why mental and nervous diseases should not be
divided up into clinical groups and concentrated effort made to cure them at
different specially-administered centres for each. The scheme now so ably put
forward by Dr. Bond would directly help to that desirable result. By the Univer¬
sities he felt sure such ideas would receive strong encouragement. The psychia¬
trist’s ambition is undoubtedly to cure insanity, but to secure this it is folly to
undertake too wide an area, and he should limit himself to cure certain forms of
insanity and allied nervous conditions and not waste his energies, as at present,
with impossibilities. He felt very strongly about this aspect of the subject and the
poor progress that was being made under present conditions.

Lieut.-Col. D. G. Thomson said that as Dr. Bond had mentioned his name as
one who had helped to bring this subject forward ten years ago he would like to
say a few words. His friend Col. Lord had referred to ?the advisability of this
reform, but he (the speaker) hoped they had gone long past that: they were now
all united in the belief that things as they exist at present were not satisfactory,
and it was for those interested in the subject to see how a remedy could be
brought about. Dr. Bond had brought forward the matter in an admirable
way, and if that gentleman was glad to find himself back in the witness-box,
members of the Association, on their part, were delighted to see him back.
Hearing Dr. Bond's paper for the first time, it struck him there were two main
points in it. In the first the author emphasised—and, the speaker thought,
rightly—the real direction in which workers should aim in this subject. It had
recently been recommended in some of the Committee work of the Association
that an endeavour should be made to establish mental clinics. As he understood
that work, it was to be rather local and special. What Dr. Bond had now brought
forward was a great improvement on that, namely, to approach the teaching
centres and even non-teaching hospitals to get them to take this subject up. It
would be very difficult to do so, as he believed that scarcely a hospital in this
country had not had painful experience of the occasional intrusion of a person of
unsound mind into the wards, and then they seemed to have experienced the terror
of being in a ship without a rudder. Real progress could only be made on these
lines, however difficult it might be to engineer the practical problems which would

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arise. The second rather new element in Dr. Bond’s paper was that concerning uni¬
fication, if possible, of the curricula that had been established, and this Association
ought to feel very proud of having succeeded in establishing such a curriculum, for
it came out of the inner bowels of the Association, by preaching to the great bodies
and getting them to institute diplomas. If those bodies could be approached so
that they would give to younger colleagues a more definite idea as to time and
cost in regard to these diplomas it would constitute a very practical advance.

Sir Frederick Mott, F.R.S., said he had been very interested to hear
Dr. Hubert Bond’s paper, and he reflected that forty years ago the London
County Council, at its inception, proposed the establishment of a hospital for
acute mental diseases in London. What became of that ? It would be interesting
to members of the Association if they would read the report on the subject. For
a long time nothing whatever was done towards establishing a mental hospital
with a clinic in London. If such had been established, it might by this time have
done very valuable work, and have attained to a high position in psychiatry,
similar to that occupied by the National Hospital in Queen Square in the domain
of neurology. He was glad to see that this Association had changed its views,
late in the day though it be, and that it had come to recognise the necessity of
such an institution. The late Dr. Maudsley, for whom members had the greatest
respect, came to him eleven years ago and offered to furnish the London County
Council with .£40,000 to build a hospital in London for the purpose of receiving
acute mental cases and for the study of psychiatry. It was a long time before the
London County Council could find a site, but they did so eventually. The hospital
was partly built when the war came, and he was sorry to say that neither
Dr. Maudsley nor Mrs. Maudsley—who was a daughter of the Conolly who took
the chains off lunatics in England, and Dr. Maudsley was better known in other
countries for his work than among his own people—neither of them ever saw the
hospital adapted for the purpose intended. That seemed to him to be a great
pity. But it had done useful work during the war, and for a time it was to be in
the occupancy of the Ministry of Pensions. The London County Council were
now anxious to get it back to the purpose for which it was founded—for dealing
with cases among the general civilian population. He did not think he was
committing a breach of confidence when he said it was hoped shortly to establish
a clinic at the Maudsley Hospital, in correlation with the asylums of the London
County Council, so that teaching could be carried out in all branches of psychiatry,
including the fundamental principles underlying the physiology, anatomy and
pathology of the nervous system, somewhat on the lines which Dr. Bond had laid
down in his paper. It was intended to get the best men possible in the country to
give such lectures. For instance, he hoped to get Dr. Macdougal, Dr. Bernard
Hart, Dr. Devine, Dr. Hubert Bond and a number of other men to give the
lectures. That course, it was hoped, would be open to all post-graduate students,
and all who were qualified in medicine. He thought it was essential that there
should be this correlation between the asylums and the Universities — if there
were a University town near. Both the University and the asylum would benefit
greatly thereby. In Scotland the University had always been associated with the
asylum, and he thought that Scotch graduates were better trained in psychiatry
than English students were. Tradition had for a long time acted in Scotland
beneficially in that way. For some time he was an Examiner in Medicine for the
Conjoint Board, and he found that the Examiners in Medicine seldom set questions
in mental disease, and consequently the classes in those subjects were rather
badly attended. He set a question on adolescent insanity, and, through the
kindness of Sir Robert Armstrong-Jones, he had two instances of it brought up—
typical dementia praecox. He, the speaker, was afterwards informed that the setting
of this question had a beneficial effect on the attendances at the classes in psychiatry.
Generally he tried to get a question in on the subject because he regarded it as very
important. It might be that after a student became qualified, one of the first cases
he would come against would be a mental one, and he would beat sea if he had not
had a training in the essentials of psychiatry. He would like to see established
clinical-assistantships, giving men six months’ experience, and he hoped to carry that
out at the Maudsley Hospital, to give men an opportunity to see whether they would
like to follow the speciality. With regard to the curriculum which Dr. Bond
laid down, life was short, and the extent of modern knowledge very great. He

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7 l

thought the system at Edinburgh was the best: there it was not hoped to cover the
whole range. He thought the best training for men who intended to become
medical superintendents of asylums was a good foundation in general medicine,
which included preventive medicine. For example, how important were deficiency
diseases in the treatment of the insane, i.t., the resistance engendered against
disease by a sufficiency of vitamines, and how detrimental their deficiency. With
regard to beri-beri, there were known to be two forms. One form did not give
any pronounced symptoms, yet there was a lowered resistance to infectious
disease. There was a great deal in being able to recognise a disease and knowing
what specialist to call in for its treatment. He congratulated Dr. Bond on his
paper, in which he laid down the right principles to adopt. Lastly, he wished to
say that when an appointment was made to a medical superintendentcy of an
asylum, it should be founded on his knowledge of the specialty, not because he
happened to be a good farmer, though he thought it needful and right he should
be head of the Institution.

Dr. R. H. Steen said one point about Dr. Bond's admirable paper, which he
was sure all the members felt very grateful for, was that he was preaching to
the converted. All in that room realised the need for clinics in psychiatry. The
difficulty of those in the specialty was with the general physician and surgeon and
the staffs of general hospitals. They were the people who required convincing
that mental clinics were required. For many years he tried to get established an
out-patient department of this kind at a certain hospital with which he was con¬
nected, and from private talks he had with members of the staff of that hospital
he gleaned they had the idea that a mental patient was necessarily an acute
maniac; they had visions of acutely maniacal persons dancing up and down the
corridors. For a long time he was unable to succeed in his efforts, but such a
department had now been started, and the other members of the staff seemed very
thankful for it. He wished to urge that all teachers of psychiatry—and they were
all members of this Association—should make a point of getting established an
out-patient department for mental cases in connection with their own particular
hospital. He did not mean that they should be altogether satisfied with that, but
it would at least be a beginning—the thin edge of the wedge—and later on beds
could be set up. It would be found that students exhibited great interest in
mental diseases, and they were keen to come to the clinics. Members of this
Association could, if they would, do a lot of missionary work by urging physicians,
surgeons and consultants generally to insist on the establishment of these special
departments in psychiatry.

Dr. Myers said he would like to point out that a mental clinic had been started
at Cambridge. The staff there unanimously favoured the institution of an out¬
patient clinic, and, thanks to the generous spirit displayed by the Board of Control
and the Medical Research Committee, it was possible to send an expert there, and
he was now spending his whole time on the out-patient work and in conducting
research in psychological medicine. This was so recent that results could not yet
be given, beyond the fact that Capt. Prideau had written expressing a fear that
he might be swamped by the large number of cases and thus be prevented from
doing research work. Possibly some help could be supplied to him. Close asso¬
ciation was being established between Addenbrook’s Hospital and the Mental
Clinic at Filbourne, where the Medical Superintendent, Dr. Archibald, was in full
sympathy. At Cambridge the Diploma had not been accompanied by teaching ;
they had been content to allow candidates for the Diploma to take their courses
anywhere, provided they showed sufficient knowledge at the examination. But he
agreed with Dr. Bond that every teaching University should aim at providing
courses in this subject, so that the candidate possessing the Diploma would be
recognised as having passed through a certain school. Dr. Bond's paper showed
the need of schools in psychiatry, and the more schools there were, with divergent
shades of thought, the better it would be for the advancement of the subject. The
Diploma was not instituted until 1912, therefore there had not been a chance of
doing much before the war, and the number of candidates had been very small.
During the war the Diploma had to be suspended altogether. The question now
was as to what could be done to encourage more candidates to come forward for
the Diploma. He felt that much could be done in the way of encouragement by
the authorities responsible for filling posts in mental hospitals, and by the granting

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[Jan.,

of leave of absence to men for the purpose of study. But so long as mental
hospitals continued to be run “ on the cheap," so long would it be impossible to
provide facilities for post-graduate education.

Dr. Good (Oxford) said it might interest members to know that for two years
Oxford had possessed an out-patient clinic for mental cases in connection with the
Radcliffe Infirmary, and it was hoped that soon there would be some beds attached.
It was not given the name “mental clinic," because that would deter people
coming to it. He had been working with Dr. William Macdougal for more than
two years, and that gentleman had, unfortunately, now retired. The work was
sufficient to keep one employed from 2 o’clock until 8, leaving practically no time
for research. People were coming in increasing numbers, and students were
taking a great interest in the work. At present there was no degree in psycho¬
logical medicine at Oxford, though the question had been mooted.

Dr. Devine said there was an international side to the question. Sometime
ago he was associated with an American unit, attached to which was a very clever
young neurologist. That officer told him he had been to Queen Square studying
neurology, he had been to Oxford and studied physiology under Sherington, and
he asked, “ Where do you learn psychiatry in England ? ” He came from Boston,
U.S.A., where some fine work was being done. He had to reply to him, “ I do
not know a definite centre here, though there are a lot of able men of international
standing, and you could go to Wakefield Asylum and see my old chief, Dr. Shaw
Bolton." For the sake of our own national credit we should have centres for
the clinical study of psychiatry and where it could be studied intensively. The
study had been pursued in this country by people under the greatest possible
difficulty, with little encouragement. Dr. Shaw Bolton, for instance, did wonderful
work in psychiatry, but who had followed it up ? There was no school, no centre
of instruction. Until centres were established for the intensive study of the
subject, so that the needs of those who intended to devote their lives to the subject
could be catered for, there would not be real progress in the specialty. Some said
psychiatry was a matter of psychology, some that it was a matter of chemistry,
still others that it was a question of pathological anatomy. His own view was
that it was not any one of these, but all of them. Until they could get at grips
with it in the proper way, until teachers, with students under them, could start
a tradition and a school, which would develop into a British School of Psychiatry,
he did not look for much real progress.

Dr. Peachel, commenting on Dr. Steen's remark, said it was not so much the
physician and surgeon as the general public whose interest should be aroused in
this subject, chiefly through the medium of asylum committees. Therefore he
thought it would be a good thing if a precis of Dr. Bond’s paper could be sent to
the various medical superintendents of asylums so that they in turn could hand
it to their particular committees. When one was right in the country—as he was
himself—one realised the need of getting into touch not only with local medical
men, but also with the local hospital, even though it might be one of ioo beds or
less. In the way of propaganda very much could be done by that course, and the
public would benefit by having early treatment.

Sir Robert Armstrong-Jones remarked that, by the courtesy of Dr. Bond, he
had had an opportunity of perusing his paper beforehand as he had been unable
to arrive in time to hear it read. He considered it was a great advantage that
a man of Dr. Bond’s eminent position should come to the Association and speak
on this subject. He (the speaker) had recently been given an opportunity of starting
a mental department at St. Bartholomew’s Hospital, and he had been appalled at
the lack of knowledge on mental subjects displayed all round. Medical men
whom he had met frankly admitted they knew nothing about insanity. How was
that hiatus to be filled ? He thought a simple method would be to afford to every
medical man a chance of seeing in his own neighbourhood a case of acute mania,
a case of acute melancholia, of epilepsy, of general paralysis of the insane, of
arterio-sclerosis, which could in many cases be modified by treating the chronic
elements in it, such as the chronic constipation and dyspepsia. The last speaker
mentioned want of sympathy and knowledge on the part of the public. He had
himself spoken to people who were on asylum committees and they neither knew
nor apparently wanted to know much about the subject. He wanted to see some¬
body kindle an interest in the matter, and the Board of Control could do this by

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1920.]

trying an experiment of a " field worker,” as in America, in one district. This
would undoubtedly kindle a public interest in the matter. When people talked
about " mental hygiene,” what did they mean by that term F They should be told
that there were two or three conditions which required to be studied in detail in
reference to the incidence of mental disease—alcohol, syphilis and the element of
heredity. He (the speaker) would like to see every medical superintendent giving
time to this matter in his own neighbourhood and foster the idea that the asylum
should be looked upon as the place where people can consult the medical staff. It
was very difficult for a senior man to keep himself up to date in cerebral physiology,
anatomy, chemistry, and so on, but the junior men could do so, and they would if
they were afforded the requisite encouragement by the authorities. They should be
allowed leave in order to study. But where were they to study ? What was needed
was coming by degrees. It was only recently that the Bethlem Royal Hospital had
started an out-patient department for cases, and St. Bartholomew’s, as he had stated,
was another example. It might interest members to hear what kind of cases had,
so far, attended the mental department at St. Bartholomew’s Hospital. They were
congenital epilepsy, some mental defectives, who had to be dealt with under the
Mental Deficiency Act, cases of dementia prarcox, early cases of general paralysis
of the insane, involutional melancholia and manic-depressive insanity, but few of
the sex or Freudian abnormalities. Altogether he had been encouraged, and he ^
had the feeling that one could do something for these cases, especially if sleep
could be procured for them, and their constipation could be corrected and electric
treatment applied. He had seen much good done by cerebral galvanism in the
war neuroses at Aldershot. In climacteric trouble, too, static electricity had been
beneficial in modifying the blood-pressure. If possible the public must be educated
in this matter, and then he felt there would be a move forward to allow medical
men in the asylums to carry on this training. It was a deplorable fact that,
though five Universities had granted diplomas in psychiatry, there were not five
candidates at each, though of course the war had had a deterrent effect. This
paper, however, indicated a move in the right direction. If one could come into
touch with people at the home, the school and children's courts, where mentally
deficient cases came to light because of small offences against social order, much
alleviating work could be done. The subject was a most important one.

The President said a letter had been received from Dr. G. A. Auden, of
Birmingham, stating how sorry he was that he could not attend, as he had hoped
to point out the desirability of making provision for the training of school medical
officers in the diagnosis of feeble-minded conditions. With regard to the
suggestion of Dr. Peachel, assuming that Dr. Bond’s paper would be published in
the Journal, the distribution of it to the quarters specified might be effected in
that way. It had been decided, earlier in the day, that members of the Association
should receive from its officers a letter dealing with the question of propaganda,
and this letter could have incorporated in it a brief statement on this subject, and
pointing out the willingness of the Association to provide reprints of Dr. Bond’s
paper, if its author saw no objection, and these could be handed to members of
Visiting Committees. That would not cost very much, and the Treasurer had
said he did not think the expense of it would be prohibitive. [Col. Thomson : It
would be Greek to many of them in its present form ; it would need translation
into ordinary language.] As there was no very decided expression of opinion
on that point, he thought it might be left over for the present.

Dr. Bond, in reply, desired to express his thanks for the very patient hearing
which had been accorded by members to his paper, and the great satisfaction
it was to him that the cnide form in which the opinions had been laid before
the meeting had led to such a kindly and encouraging discussion. As the time
was now late, he hoped he might be forgiven if he did not do full justice to
what the several speakers had said. All were exceedingly glad to see Col.
Lord here. Members knew the immense amount of work he had been called upon
to do at the Horton County of London War Hospital, and some time ago it was
reported that he was far from well. He agreed with that gentleman that many
hard things were said about specialism, some of them, no doubt, just because
specialism without a good grounding in general medicine was all to the bad. In
the other way, however, it was to the good, and he agreed that concentration upon
small departments of their larger work would be the best means of making

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[Jan.,

progress. He felt grateful for Col. Thomson’s remarks, also for the goodwill with
which the Colonel allowed him to take up the threads of his own pioneer work.
That speaker laid stress on the reluctance of general hospitals to confer facilities
for studying mental cases, and in that he was only speaking what was the fact.
But if staffs of hospitals based their experience upon the effect of one acute case
in their wards, that they should take up a hostile attitude on this question was
what one would expect, because the mixture of mental and general cases in the
same wards must be profoundly bad for both. One wanted to see them in wards
under the same great label as the wards for general cases, namely the name of the
general hospital in question. What Sir Frederick Mott said would surely give
them food for thought. Some of Sir Frederick’s comments sounded as if he took
some exception to the formidable nature of the diplomas; but he, Dr. Bond, laid
stress himself on not trying to teach too much detail, and upon concentrating upon
the " institutes ” of the required subjects. Therefore he felt that Sir Frederick and
he were at one on the matter. He was also glad Sir Frederick insisted upon
particular attention being paid, in whatever teaching psychiatrists were able to do,
to the relation of this branch to general medicine, an insistence which, if included
in any scheme—and there was a precedent in the case of the diplomas—would
probably abolish such terms, which he disliked, as " alienism ” and “ alienists.”
Dr. Steen declared that what the paper did was to preach to the converted.
He knew Dr. Steen was right in that remark, and in bringing this paper before
the Association it was with no such ideas as that the members stood in need of
conversion on these points. His hope had been that the reading of the paper here
might lead to some decision being taken—by way of the formation of a Com¬
mittee or any other means—again to carry out propaganda work in this and other
places where there appeared to be some stagnation. With regard to the idea of
Dr. Peachel that a precis of the paper should be printed and circulated to medical
superintendents with a view of it getting into the hands of members of visiting
committees and others, that was a flattering suggestion, but he thought there should
be pause before it was adopted, and that time should be taken for consideration as
to the best means of securing progress in our speciality. Still, whatever the
Association chose to do with regard to the paper was a matter entirely for them.
He desired to express his thanks to Sir Robert Armstrong-Jones for what he had
said. It was with great difficulty Sir Robert reached the meeting at all. It was
particularly interesting to know that a mental department had been founded at St.
Bartholomew’s Hospital, with all its ancient traditions. That gentleman was right
when he assumed that the object of the present paper was to kindle a wide interest
in the subject, not among members of this Association, but among the public. And
the point in the letter from Dr. Auden was important. He, Dr. Bond, was not
sure that the syllabuses of the different Universities granting the Diploma dwelt
sufficiently on the question of mental deficiency, yet it loomed so large now that it
might be well to press on the University authorities this Association’s opinion
as originally expressed in their memorandum—that there should be optional
subjects provided for in the Diploma conditions.

IRISH DIVISION.

The Autumn Meeting of the Irish Division of the Medico-Psychological
Association was held on Thursday, November 6th, 1919, in the Royal College of
Physicians.

Members present: John M. Colies, K.C., LL.D., in the Chair, Lieut.-Col. W. R.
Dawson, Drs. Hetherington, Gavin, Nolan, Greene, H. Eustace, Keane, Harvey,
Mills, J. O'C. Donelan, Rutherford, and Leeper(Hon. Divisional Secretary).

Before the business of the meeting was proceeded with, it was proposed by Dr.
Hetherington and seconded by Dr. Eustace :

“ That this meeting of the Irish Division of the Medico-Psychological Associa¬
tion desires to place on record its extreme regret at the loss which the Association
has sustained by the death of Dr. Drapes, who was one of its oldest and most
valued members, and this meeting expresses itself fully in accordance with the
action of the Hon. Secretary, Dr. Leeper, in sending, at the time of the sad event,.

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to the members of the deceased's family a wreath and letter of sympathy in the
name of the Irish Division."

The resolution was passed in silence, the members standing in their places.

The minutes of the previous meeting were read and signed.

It was proposed by Dr. Nolan, seconded by Dr. Mills and passed unani¬
mously :

“ That in the appointment of an Editor to the Journal of Mental Science, to
fill the vacancy occasioned by the death of the late lamented Dr. Drapes, the Irish
Division desires unanimously to place the name of Lieut.-Col. Dawson before the
Council as a suitable successor and as representing this country."

Dr. Mills drew attention to the fact that the date of the Summer Meeting
fixed in 1920 would possibly interfere with the Annual Meeting of the British
Medical Association, and it was decided that the date fixed for the Summer
Meeting should again be considered at the next meeting.

Dr. Nolan next introduced his discussion upon “ The Irish Asylum Service and
Its Relation to the Ministry of Health Act."

“ I venture to introduce this discussion with some degree of doubt, as I am not
quite sure that there exists an Irish Asylum Service in a departmental sense, and
if there is, that it has any relation to the Ministry of Health Act, at least so far as
the Public Health Council in Ireland, as created under that Act, is concerned. In
any event, a discussion may help to throw light on many doubtful matters, and
possibly be the means of shaping a policy or plan of campaign, to enable this
Division of the Medico-Psychological Association to express reasoned opinions as
to the future of the Irish asylums, their patients, staff and administration, as well
as on allied matters of public health.

" So far it would seem that the attitude of those responsible for the Ministry of
Health Act, beyond the mere statement in that Act, that it is to deal with ‘ the
treatment of mental defects,' has shown, as far as I am aware, no disposition to
put that clause into effect, and it is remarkable that the opening address of the
Chairman of the Health Council contains no reference to mental disease, nor does
the Council itself embrace any expert representation of the interests of the insane
and the general question of insanity, its prevention, increase, and efficient treat¬
ment.

“ Possibly all this is being dealt with by the inspectors of lunatics in secret
treaty with the promoters of the Act. If so it is in good hands, and any action of
this Division will no doubt be in support of and accord with their proposal. But I
submit that the matter is one which should be handled openly and above board, and
in the first instance by those who have a practical everyday knowledge of the
public asylums. Hence, I venture to ask you to-day to consider what bearings
this Act may have on those institutions. Personally, I see great potentialities for
good, or for evil, and much must be considered before we can see clearly how to
secure the maximum of the good and the minimum of evil.

" I do not propose to read you any hard and fast conclusions, but simply to name
the points for consideration.

“(1) As to Insanity.

" Pathological research in laboratory work, now optional, to be made obliga¬
tory.

“ Treatment of incipient insanity by special expert advice, say at several centres
in each district.

" Institutional treatment.

“ Special specific treatment.

“ Boarding-out. Now that conditions of life have improved and labour con¬
ditions are so difficult, more toleration would be extended to defectives received
into family care.

“ (2) The Staff.

" Its adequate pay and training. Its status as a nursing body restored by
making strikes without notice a criminal offence.

"(3) Administration of Public Asylums.

“ Augmentation of the grant in aid. Adequate medical staff, with special aid in
matters of dentistry, etc.

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“ Other matters—as to the position and powers of the inspectors, etc., and legal
amendments to existing Act, as discussed at the Summer Meeting of the Division
at Downpatrick in 1918—might also be included in a Bill.

“ It would seem tome, in any event, that it is the clear duty of this Division to
formulate a constructive policy of action in all these matters, in the event of any
legislative measures which may be proposed later. Any such policy should be
well considered.

“ I would appeal to the members to treat the matter from a broad, unselfish
standpoint, keeping only in view as a goal whatever is in the best interests of the
afflicted insane.”

A full discussion followed Dr. Nolan’s opening statement, in which almost all
the members present took part. It seemed to be the general feeling that a strong
central controlling body co-ordinating the Irish Asylum Service in the interests of
the insane and standardising and improving the treatment and general manage¬
ment of asylums was urgently needed, and should be incorporated into any legis¬
lative measure dealing with the same. The various points of Dr. Nolan’s paper
were discussed and generally approved of. It was finally proposed by Dr.
Donelan, seconded by Dr. Gavin and passed unanimously:

“ That the Parliamentary Sub-Committee of the Irish Division be directed to
consider matters relating to the central control of the asylum service and any
cognate matters, and to furnish a report to the Irish Division at its next meeting,
and that the names of Dr. Colles, Dr. Greene and Dr. O’Doherty be added to the
Irish Division’s Parliamentary Sub-Committee.”

The Ho.v. Secretary mentioned that Dr. Eustace kindly invited the Division to
hold its Spring Meeting at Hampstead House. Dr. Eustace’# invitation was
accepted with thanks.

NORTHERN AND MIDLAND DIVISION.

The Autumn Meeting of the Northern and Midland Division was held by the
kind invitation of Dr. A. J. Eades at the North Riding Asylum, Clifton, York, on
Thursday, October 30th, 1919.

The President, Dr. Bedford Pierce, presided.

The following fourteen members were present: Drs. G. L. Brunton, A. J.
Eades, S. Edgerley, C. L. Hopkins, G. R. Jeffrey, W. S. Kay, R. M. Ladell, H. J.
Mackenzie, H. D. MacPhail, J. Middlemass, J. E. Middlemiss, B. Pierce, J. B.
Tighe, T. S. Adair ; and three visitors—Drs. H. J. Drake-Brockman, J. Lowther
and L. R. Oswald (Scottish Division).

Apologies for non-attendance were received from several members.

The minutes of the last meeting were read and confirmed.

A ballot was taken for Henry George Drake-Brockman, M.R.C.S.Eng.,
L.R.C.P.Lond., Assistant Medical Officer, the Mental Hospital, Middlesbrough.
Proposed by Drs. Geddes, Hopkins and Adair as an ordinary member of the
Association, and he was unanimously elected.

On the proposal of Dr. Eades, seconded by Dr. Middlemass, Drs. S. R. MacPhail
and Bedford Pierce and Major Street were unanimously re-elected to form the
Divisional Committee for the next twelve months.

' Contribution.

Dr. G. Rutherford Jeffrey then read a paper entitled “ Notes on Three
Cases, showing the Value of Hypnosis and Suggestion as an Aid to Treatment.”
The first case was that of a lady who was suffering " presumably from mania
associated with gestation." She broke down mentally from worry and was very
restless and exalted. She was hypersensitive,, and as her condition "was only a
passing emotional storm ” it was thought it might be checked if her mind could be
“ completely calmed.” She was put under a light hypnosis and it was suggested
to her that she ” would sleep all right and awaken feeling well.” She slept for
nine hours and awoke feeling much better. From this time she steadily improved
and made a good recovery. The second case was one in which a distressing

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symptom, via., the "most frightful desire to injure his wife and children," was
made to disappear by suggestion with the aid of hypnosis. Though the patient,
who was neurasthenic and depressed, was not cured, he entirely lost the idea, and,
indeed, would hardly believe that it had ever existed. The third case was one of
neurasthenia and shell-shock in an officer who had on two occasions been
blown up and buried. He fell in love with a girl, and after behaving rudely to her
mother was told that the parents did not wish to have anything more to do with
him. This worried him and “aggravated all his neurasthenic symptoms." He
could not bring himself, however, to write and apologise and accept the decision.
He was put to sleep under a light hypnosis and a suggestion was made to him
that he should write. On awakening he immediately put this into effect before
attempting to do anything else. After this he certainly improved.

The first case is really one of “ marked emotionalism," and shows how the
patient’s mind righted itself after being put into a “ condition of blank and calm."
The second shows how a distressing obsession can be got rid of, and the third
indicates that a “ persistent ‘ aboulia ’ causing a more or less severe mental paresis "
can be abolished by suggestion. Dr. Jeffrey says that, from his experience, he is
"convinced that hypnosis and suggestion treatment have an important therapeutic
place in the treatment of the psycho-neuroses,” and that "given a suitable case it
is worthy of trial.”

An interesting discussion followed, in which most of the members present took
part.

Dr. Pierce made some reference to forthcoming changes in lunacy administra¬
tion, and this was followed by a talk about the nursing examination and the effect
that the altered conditions of asylum work might have upon it.

The following resolution was then proposed by Dr. Middi.emass, seconded, and
unanimously carried, that "in the opinion of the Northern and Midland Division of the
Medico-Psychological Association the question of the revision of the Handbook
should now be considered by the Education Committee with a view to its improve¬
ment in certain parts; at the same time this Division is of opinion that the present
standard of teaching and of the examination for the nursing certificate of the Asso¬
ciation should not be reduced."

A very interesting and enjoyable meeting was brought to a close, a hearty vote
of thanks having been accorded to Dr. Eades for his kind hospitality.

SOUTH-WESTERN DIVISION.

The Autumn Meeting of the above Division was held at University College,
Bristol, on Friday, October 24th, 1919, at 2 p.m.

The following members were present: Drs. Brown, Devine, Eager, Lavers,
Mules, MacBryan, Nelis, Soutar and Thomas, and the Hon. Divisional Secretary
(Dr. Bartlett).

Dr. Soutar was voted to the Chair.

Letters of regret for non-attendance from Drs. Aveline and MacDonald were
read.

Dr. Bartlett was nominated as Hon. Divisional Secretary.

Drs. MacBryan and Soutar were nominated Representative Members of Council.

Dr. Devine very kindly extended an invitation to the Division to meet at the
Portsmouth Mental Hospital, April 23rd, 1920.

The Chairman alluded to the loss the Association had sustained in the recent
deaths of Dr. Mercier, Dr. Drapes and Dr. Wiglesworth, which were all recorded
with deep regret by all members present.

Dr. Eager then read his paper on " Head Injuries in Relation to the Psychoses
and the Psycho-neuroses."

The Chairman expressed the unanimous appreciation by the audience of the able
work of Dr. Eager in this valuable record of the after-effects of head injuries.

Drs. Soutar, Devine, Lavers and Bartlett joined in the ensuing discussion.

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SCOTTISH DIVISION.

A Meeting of the Scottish Division of the Medico-Psychological Association
was held in the Royal College of Physicians, Queen Street, Edinburgh, on Friday,
November 2ist, 1919.

Present : Drs. Buchanan, Clarkson, Crichlow, Fraser, Henderson, Hotchkis,
Kerr, Macdonald, T. C. Mackenzie, Tuach Mackenzie, G. D. McRae, Orr, G. M.
Robertson, Ford Robertson, Maxwell Ross, Shaw, Skeen, H. Yellowlees, and
R. B. Campbell, Divisional Secretary.

Dr. G. M. Robertson occupied the Chair.

The minutes of the last Divisional Meeting were read and approved, and the
Chairman was authorised to sign them.

The Secretary intimated apologies from Drs. D. G. Thomson, Bower, Easter-
brook, Dods Brown, Ross, Steele, Ferguson Watson.

The Business Committee was appointed, consisting of the nominated member,
the two representative Members of Council, along with Dr. G. M. Robertson, Dr.
D. K. Henderson, and the Divisional Secretary.

Drs. T. C. Mackenzie and G. Douglas McRae were nominated by the Division
for the position of Representative Members of Council, and Dr. R. B. Campbell
was nominated for the position of Divisional Secretary.

The following candidate after ballot was admitted to membership of the
Association :

Ian D. Suttie, M.B., Ch.B.Glasgow’, Assistant Medical Officer, Glasgow Royal
Asylum. Proposed by Drs. Oswald, Henderson, and Campbell.

The Secretary submitted a letter from the President of the Association
suggesting that the Scottish Division should nominate a representative from
Scotland to act as Chairman of the Educational Committee, and the Division
unanimously resolved that Dr. L. R. Oswald be nominated for the position. As
Dr. Oswald was not present at the meeting, it was resolved that in the event of
his not seeing his way to accept office, Dr. G. M. Robertson should be nominated
in his stead—Dr. Robertson consenting to do so.

Dr. Ford Robertson read an interesting and very instructive paper on “ The
Relation of Infections to Mental Diseases,” which was followed by a discussion, in
which several members took part.

Dr. MacDonald referred to the importance which the National Asylum
Workers’ Union had placed on the teaching and training of the Nursing Staffs of
Asylums, and he suggested that, in view of the high wages now paid nurses and
attendants, the entrance fees for the examinations for the Association’s Nursing
Certificate should be increased.

After some discussion it was unanimously resolved to instruct the Secretary to
send a Resolution from the Division to this effect to the Secretary of the
Educational Committee.

Dr. G. M. Robertson referred to the objections which the National Asylum
Workers’ Union had raised regarding the employment of female nurses in male
wards of asylums, and in view of the probability of the Union taking action in the
matter, it was unanimously resolved to draft a Memorial in support of the existing
method of employing female nurses to nurse suitable male cases, and that all
medical men interested in the treatment of mental diseases in Scotland should have
an opportunity of signing the memorial before sending it to the General Board of
Control, District Boards of Control, and Royal Asylums Boards.

A vote of thanks to the Chairman for presiding terminated the business of the
meeting.

A dinner, after the meeting, was held in Messrs. Ferguson and Forrester's, and
was well attended.

THE LATE DR. CHARLES ARTHUR MERCIER.

Sir George Savage writes :

I feel that in some ways the characteristics of Mercier were better understood by
the general public than by the medical profession, and better by the medical press
than by our specialist journals, yet I believe it is due from us to record our
personal regard for Mercier and our regret at his death.

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Indirectly, Mercier’s name came under my notice when he was a student at the
London Hospital. My father-in-law, Dr. H. G. Sutton, whose medical clerk I
believe Mercier was, spoke of his ability, but also of his unbounded self-assertion,
for he had the audacity to go round the wards and alter some of the physician’s
prescriptions. From a student who would do this a good deal might be expected.

Dr. Mercier began his association with insanity by becoming Assistant Medical
Officer at Stone, The City Asylum, near Dartford, in 1882. He was there till
March, 1885. His senior was altogether unlike Mercier and their relationships
were not cordial. Mercier was the student and was not distinguished in sports or
social duties. The incompatibilities increased and Mercier gave up his post, and
in a short time arrived at consulting work. He became Resident Physician at the
Flower House, Catford, a private asylum which had belonged to the Winslow
family.

Here he was more in his element; the house and grounds were attractive and the
patients not numerous. His genial and friendly relationship with the patients gave
him his deep insight into disordered states of mind, which is such a marked
character of his writings.

He was greatly influenced by the teaching of Hughlings Jackson, who, in turn,
was the follower of Herbert Spencer. As a writer on psychological subjects he
must be compared with Maudsley, whose life work was so similar to that of
Mercier, and whose books have such a remarkable parallelism in titles and subjects
to his.

Though polished and clear, the writings of Mercier will not, in my opinion,
remain as medical classics as have those of Maudsley. Mercier had the strength
of his failings. He was a perfect bulldog in his pertinacious hold of his own
ideas, and these were not always true. Take, for example, his tiresome insistence
on the distinction between insanity and unsoundness of mind. He had for twenty
years or more an obsession that he alone had recognised this though it was more
than once made clear that this was not the fact.

He was a most prolific writer and a very able speaker. I knew him as a member
of the Casual Club, a social club where any and every subject was discussed—cer¬
tainly without any regard to the private feelings of previous speakers. The
discussions were as a rule carried on vigorously but without loss of temper.
Mercier was at his best here.

Whether later in the Journal some special articles appear on his literary labours
must rest with the Editor, but it is a task not to be readily undertaken. A rather
wild suggestion might be made that for a Maudsley lecture the parallelism
between the two be studied.

For the past few years one has looked upon Mercier as a kind of hero, for one
recognised that he knew he was fated and that nothing could stop the fatal
issue of his disease, yet with superb pluck he stuck to his work and seemed still
as briskly combative as ever. He has left a great gap in our ranks, and with
reverence we leave him.

November 28 Ih, 1919.

Dr. H. de M. Alexander, Medical Superintendent, of Kingscat Mental
Hospital, Aberdeen, writes : " In your last number of the Journal you ask for
any ‘recollections’ of the late Dr. Mercier. He was good enough to bother
writing to me sometimes, and the enclosed extracts—though they possibly are not
what you want—are rather typical of him. Like others I have more characteristic
remarks of his, but they are personal."

" Relative to the absence of an index in the second edition of his text-book :
‘As to the index, let me confess that my querulous remarks were dictated partly
by laziness and detestation of the task of making an index, and partly by
annoyance at the laziness and inefficiency of those reviewers, and they are the
majority, who form their opinion of a book from reading the preface and looking
at the index. If I must be honest and frank, I have been abominably annoyed
and have been made to waste much time by the absence of the index in that
very book.’ (June 28 th, 1917.)

" I believe one reason my Text-book does not sell is that it is only crown 8vo
in size; students like a good pretentious-looking book, and plenty of paper for

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their money. What is printed on the paper does not much matter, so long as
there is plenty of paper.” (September 2.\th, 1917.)

"Imbecile v. Feebleminded: ‘The imbecile is distinguished from the feeble¬
minded by this—that the feebleminded can, and the imbecile cannot, under
efficient supervision and control, earn enough to keep body and soul together.
When controlled and supervised his labour has this market value. The labour
of the imbecile costs as much or more in supervision and control than the product
will bring in the market.’ (June 21 st, 1917.)”

SIR JAMES CRICHTON-BROWNE AND THE MAUDSLEY LECTURE
LETTER OF ACCEPTANCE.

Crindau,

Dumfries, N.B.;

August yth, 1919.

Dear Major Worth, — I am much gratified by the invitation of the Medico-
Psychological Association which you have conveyed in such kind terms, and shall
be glad to deliver the first Maudsley Lecture in London in May, 1920.

I am keenly conscious that there are many who are much more capable than I
am of representing the most advanced stages of that movement in mental science
which Maudsley did so much to inaugurate in this country, but I have this qualifi¬
cation—and it is that no doubt that has procured me your honouring invitation—
that I was a contemporary worker with him in the field which he so intensively
cultivated from the beginning to the close of his career.

Believe me,

Yours very faithfully,

(Signed) James Crichton-Browne.

Major R. Worth, M.D., etc.

IMITATIVE SUICIDES.

In the course of a recent inquest Dr. F. J. Waldo, Coroner of the City of London,
made some interesting observations on the imitative factor in the causation of
suicides. He pointed out that, as was his custom, he had merely read in court two
or three material, relevant lines from the bulky correspondence found on the body
of the deceased. The jury and others interested in the case had had an opportunity
of perusing the documents in full. The reading of details in court lead to their
publication by the press, which not only gave pain and distress to the relatives,
but, he believed, often led to further suicides by suggestion and incitation. For
example, a short time ago three brothers, one after another, took their own lives
by placing their heads in the same stove with the gas turned on. A lessening in

the number of suicides would undoubtedly follow the suppression by the press of

detailed reports of sensational and “ interesting ” cases of suicide. If any class of
case might advantageously be held in private by Coroner and jury to the

exclusion of the press and other members of the public, he thought it was

that of a certain number of selected cases of suicide. He did not for a moment
suggest, for instance, that cases in which the good name of an individual was at
stake should be held other than in the presence of press and public. The return
of weapons, such as pistols, knives, ropes, etc., by which suicide was accomplished,
to relatives also in some cases acted injuriously by suggestion and incitation. Dr.
Waldo added that he was a great believer generally in the usefulness of the full
publicity of the Coroner's court, and he trusted that before long the pre-war con¬
stitutional and uniform method of sitting in all cases of inquisition with a jury
would be resumed .—Medical Officer, October 25th, 1919.

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8 I

TUBERCULOSIS AND INSANITY.

Both Increased by War Disease.

Recent reports of health officers and others call attention to the fact that tuber¬
culosis is increasing. There are various explanations, but most of the ones which
we have seen are vague and unsatisfying. At the same time, we are told from
other quarters that insanity and functional nervous disorders are on the increase
also.

So far as can be gathered, both these fears are justified by the event. The
point that arises and must be considered is whether there is any connection
between the two phenomena. Is the increase of tuberculosis due to the same
causes as the increase of insanity ? Or are the evils without relationship one to
another ?

Some time ago a writer who adheres to what, for convenience, is spoken of as
the New Medicine, ventured to prophesy that both tubercle and insanity would
increase after the war. He based his prophecy on the following considerations :

A vast number of men and women have in these last years become infected by
diseases which from their nature are very difficult to eradicate. These diseases,
which include malaria, dysentery, trench fever, the typhoids—in some cases—and
venereal diseases, act as chronic poisons. The poisons probably exert a specific
effect on the nervous system. The result is that the level of bodily expenditure on
any given effort is raised and the victim tends to fall into a state of exhaustion.

If he is not cured he remains in this state of exhaustion and exhibits marked
neurasthenic symptoms, weakness, instability, mental weariness, and soon. Bit by
bit the " margin of safety ” which protects from disease, whether of the body or the
mind, is worn away.

Now it seems to be the case that tubercle does not in most instances seat itself in
a healthy soil. It tends to follow other infections when the resistance of the patient
is low. It tends to ameliorate when the bodily resistance is raised against it.

Reduced Health Margin.

In the same way traits of mental instability, which may be hereditary or
acquired, do not tend, as a rule, to show themselves until some secondary factor
has reduced the margin of safety represented by health. In other words, at some
given point of weakness and exhaustion, a man, apparently mentally sound, may
uncover bis predisposition and become insane. The healthy man is able by the
exercise of his will to restrain the impulse which would unseat his reason ; the sick
man is not so able. The insanities of the puerperium may be taken as illustrations
of this.

Consequently the victim of war disease—and his number is legion—is more liable
to attack than his uninfected neighbour. Tuberculosis and insanity may both assail
him with a probability of success which did not exist before he fell a victim. He
is, in a medical sense, a fortress the outer fortifications of which have fallen.

The matter is important from the point of view of pensions. In cases in which
tubercle has begun since demobilisation the victim is entitled to an inquiry into his
history during the war. If it is found that he is infected with a disease of war in
addition to his consumption—and this is by no means as rare as might be thought
—he is entitled to relief. The same thing applies in the case of insanity .—The
Times, September 8th, 1919.

CARE OF DEFECTIVES.

Estimates of ^1,660,000.

In a memorandum issued yesterday on expenditure likely to be incurred under
the Mental Deficiency (Amendment) Bill, it is stated that it appears probable that
if full use were made of the Act during the next five years provision should be
made for the maintenance in institutions or under guardianship of about 21,700
defectives. It is estimated that the average annual cost of maintaining defectives
in institutions will be about £60 a head. The total sum required, therefore, will

LX VI. 6

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[Jan., 1920.

be about £1,300,000, with another £100,000 for administrative expenses. Of
this amount half, or £700,000, will be refunded to the local authorities from the
Exchequer. The whole of this sum will not be required at once, but may reach
the estimated figure in about five years’ time. It is estimated that in Scotland
provision should be made for the maintenance of about 4,000 defectives, and the
cost of these at £60 a head and other items is expected to aggregate about
.£260,000, of which half will be repayable from the Exchequer .—The Times,
November 27th, 1919.

APPOINTMENT.

Steen, Robert Hunter, M.D., M.R.C.P.Lond., Out-patient Physician for
Psychological Medicine, King’s College Hospital, Denmark Hill, London.

ERRATUM.

The 67 th Annual Report of the Inspectors of Lunatics ( Ireland ) for 1917 : A
correction .—Page 264, line 47, the reviewer has made an error in the column of
the table referred to. The figures quoted refer to deaths ; 8'8 per cent, is the
percentage of deaths on the daily average.— Eds.

NOTICE TO CONTRIBUTORS.

N.B .—The Editors will be glad to receive contributions of interest, clinical
records, etc., from any members who can find time to write (whether these have
been read at meetings or not) for publication in the Journal. They will also feel
obliged if contributors will send in their papers at as early a date in each quarter
as possible.

Writers are requested kindly to bear in mind that, according to Ltx(a) of the
Articles of Association, “ all papers read at the Annual, General, or Divisional
Meetings of the Association shall be the property of the Association, unless the
author shall have previously obtained the written consent of the Editors to the
contrary.”

Papers read at Association Meetings should, therefore, not be published in other
Journals without such sanction having been previously granted.

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PRINCETON UNIVERSITY

JOURNAL OF MENTAL SCIENCE, APRIL, 1920.

Thomas Drapes, M.B.Dubl., L.R.C.S.I.

Obiit October 5th, 1919. President-Elect 1910-11.

Co-Editor of Journal since 1912.

Adlard & Son & l^'cst Newman , Ltd.

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PRINCETON UNIVERSITY

THOMAS DRAPES,

[April,

he was able to marry in 1875, his wife being a member of an old
Enniscorthy family, the Prestons of Salville. In 1883, however, the
position of Resident Medical Superintendent of Enniscorthy Asylum fell
vacant on the death of Dr. Joseph Edmundson, and Dr. Drapes,
deciding to become a candidate, was elected on September 4th
of that year. Thenceforward until his resignation last May he managed
the affairs of that important institution with a success to which those
connected with its administration have borne testimony. As in most
asylums at that period, the accommodation and equipment of the
Enniscorthy institution left a good deal to be desired, and Dr. Drapes
speedily induced the managing body to initiate a series of improvements,
as the result of which the buildings were enlarged by the addition of two
new wings, a laundry, and a kitchen, while the interior of the older part
was remodelled and improved. As time went on other matters received
attention. A new system of drainage was installed, as well as a new
water supply and a general heating plant, while in comparatively recent
times wise advantage was taken of an opportunity of purchasing a
derelict mill, which rendered it possible to supply the asylum with
electricity for lighting and power purposes at a very economical rate.
Although the structural improvements effected during Dr. Drapes’ period
of office irfvolved considerable expenditure, there is no doubt as to their
wisdom and necessity, and it has been well stated that the manner in
which they were carried out “ will long remain a monument to his
prudence, foresight, and remarkable business capacity.” Meanwhile
the training of the staff in the proper care of the insane was not
neglected, while in his dealings with the members he always showed
not only a desire to secure efficient performance of duty, but also
a kindly solicitousness for their welfare which rendered the relations
between them of a peculiarly friendly character. This was acknow¬
ledged on his departure from the asylum by a valuable presentation;
and when the sad news of his death came, it may safely be said that,
outside his family and personal friends, no more sincere regret was felt
than amongst those who had been his subordinates.

But structure and administration are but means to an end, and,
though successful in these directions, Dr. Drapes was always first and
foremost a physician; and it was in his personal and professional
relations with the afflicted beings who passed through his hands that
the bent of his mind and character were most conspicuously shown,
while the unfailing kindliness and conscientious care which characterised
his attitude to his patients were no more conspicuous than the keen
medical and scientific interest which marked his observation and
treatment of the forms of disease from which they were suffering.

On his appointment as Resident Medical Superintendent he joined
the Medico-Psychological Association, and it is not too much to say

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1920.]

that his intimate connection with that society, which brought him into
touch, not only with the alienists of Ireland, but also with the leading
members of the specialty in Great Britain, afforded him some of the
happiest moments of his life, while providing opportunities for the
expression and discussion of his views which were advantageous both
to himself and his fellow-members. In his first paper read before the
Association he dwelt on the difficulties which beset the medical officer
of a country asylum who desires to keep abreast of the progress of
science and so to do his best for his patients; and there can be no
doubt that it was his constant effort to carry out in practice the very
practical suggestions which were there made for overcoming them.
During his whole career he continued an active member, contributing
to the Journal of the Association a series of valuable papers on the
statistical, clinical, and other aspects of his subject, which were marked
by careful observation, clear reasoning, and lucidity of expression, as
well as other useful work in the form of reviews; while at the various
gatherings of the society his genial presence, no less than his alertness
of intellect and ready power of fluent speech, made him a welcome
figure. It was therefore natural that the Association should eventually
mark their appreciation of him and his work by choosing him for the
highest office in their gift, that of President, which he should have held
during the session 1911-12. Unfortunately his health in the spring
of 1911 gave so much anxiety that he felt obliged to withdraw, but he
was able to attend the annual meeting at Dublin in July, 1911, and
contributed to its success by reading an excellent paper on “The
Personal Equation in Alienism.” In the following year (1912) it was
felt that fuller advantage should be taken of his literary ability, and he
was unanimously elected Co-Editor of the Journal of Mental Science —a
choice which was more than justified in the years that followed. Up to
midsummer, 1915, his editorial duties were mainly routine, except for
one or two occasional articles; but at that time the Senior Editor,
Dr. Lord, having taken a commission, was obliged to relinquish work
on the Journal owing to his military duties, and thenceforward until the
end of the war Dr. Drapes had sole responsible charge, though well
supported by the Assistant Editors. Both his mental endowments and
his training peculiarly fitted him for such work, for with accuracy,
punctuality, and conscientiousness he combined a thorough knowledge
of English and a sound working acquaintance with French and German,
while his keenness and quickness of intellect must have rendered
editorial routine easier for him than it would have been for many.

In his views on the disputed questions of psychology Dr. Drapes’
tendency was in the direction of conservatism, and in addition he was
too clear and honest a thinker to accept without question new opinions,
no matter how eminent the authority by whom they were advanced.

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THOMAS DRAPES,

[April,

Thus he never could bring himself to adopt the doctrines of Kraepelin,
to many of which he was in outspoken opposition, and his attitude to
psycho-analysis may probably be accurately judged from a statement
in the prefatory note to his translation of Delage’s Une Psychose
Nouvelle (published in the Journal of Mental Science of January, 1917),
to the effect that Freudism “ in the view of many sober thinkers is, in
much of its theory, scientifically unsound, and at least capable of
becoming demoralising in practice.” With the philosophic position
of Maudsley, however, he was to a great extent in sympathy, his desire
for orderly system and definiteness of thought inclining him, as it did
many able men of his period, in the direction of a materialistic conception
of mind. He was not, however, disposed to go as far as his leader,
and he found it possible to reconcile a material attitude towards
scientific truth with adhesion to the essential doctrines of Christianity,
if we may judge from the fact that he took an active interest in the
work of the Church of Ireland in the parish and diocese in which he
lived.

For the various spheres of activity to which allusion has been made
by no means exhausted the interests of his many-sided mind. Thus he
served on the Synod of his diocese, as well as holding other Church
offices, and he took a particular interest in temperance work ; while his
love for music—he was at one time a good pianist—led him to act for
thirty years as secretary of the local Choral Union, the members of
which marked their gratitude to him by a handsome presentation on his
leaving the district. He was also no mean photographer, was interested
in chess, and was a keen croquet player and an occasional golfer; and
he took his part in all the social life of the neighbourhood, his geniality
and sense of humour making him a most pleasant companion and
winning him numbers of friends, to whom his loss has brought unfeigned
sorrow.

Although, beyond some degree of deafness, the passing years seemed
to have little effect upon him, there can be no doubt that a certain
fatigue was making itself felt, which was probably accentuated by the
multitudinous anxieties and occupations of the last five years, and lately
by the spread of the general industrial unrest to the staffs of asylums,
though happily at Enniscorthy tact and good feeling rendered it
possible to avoid a strike, such as unfortunately occurred in some
other institutions; and when, with the approach of the County Council
elections, it became evident that the new Asylum Committee would
differ in many respects from that under which he had worked on such
friendly terms for so many years, he decided that the time had come
for him to give place to a younger man, and he severed his long
connection with Enniscorthy Asylum on May 15th, 1919.

Great as the wrench must have been in leaving the place with which

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1920.]

he had been associated for nearly half a century, the rest and relief
from responsibility gradually produced their effects, and even shortly
before his death it was noticed how well he was looking. His new
house and its arrangements provided him with pleasant interests, and his
connection with the Medico-Psychological Association and its Journal
kept him in touch with lunacy matters, and enabled him still to do
useful work in the cause of the mentally afflicted. At the annual meeting
of the Association at York in July, 1919, he was his old cheerful self,
and his many friends there little thought that they had seen him for the
last time.

All went well until the death of his brother-in-law rendered it
necessary for him to return to Enniscorthy at the end of last September,
and on the journey he contracted a chill which after his return home
developed into double pneumonia, and brought his life to a close on
Sunday, October 5th, 1919. His widow, a daughter and four sons
remain to mourn his loss. Their grief has been shared, not only by
his close personal friends, but by the committee of his asylum,
his subordinates on the staff, and all, it is not too much to say, with
whom his varying activities brought him in intimate contact.

Dr. Drapes, as has been said, succeeded as an administrator, but he
was first and foremost a physician, and amid so many calls upon his
time he never failed to keep up with the advance of knowledge, not
only in his own subject, but in general medicine. Had his lot lain
elsewhere, the quickness and lucidity of his intellect and his ready
power of expression with voice and pen would have rendered him an
admirable teacher, and there is little doubt that he would have taken a
position at least more conspicuous in the world’s eyes than that which
he was called to fill; but it may well be doubted whether such a
position would have given him greater happiness in his life, while it
could not have increased the respect and affection in which he was
held. An upright and honourable gentleman, as free as a man may be
from self-seeking and self-assertion, quiet and unassuming in manner
despite his knowledge and attainments, cheerful, humorous, hopeful,
ready to do what he could for all, he was, as has been well said,
“ one of the kindest, straightest, and most loyal friends a man could
ever have,” and he leaves a memory which any might envy.

W. R. Dawson.

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IDENTITY OF THE PSYCHOSES AND NEUROSES, [April,

Part I.—Original Articles.

The Identity of the Psychoses and the Neuroses. By John
Macpherson, C.B., M.D., F.R.C.P.Edin, Commissioner of the
Board of Control for Scotland.

Half a century ago Maudsley wrote (*) “ A pregnant but very difficult
question of which little or no thought has ever been taken by writers on
insanity is—What is the cause of the particular form which the disorder
takes in a given case? Why does it assume one complexion rather
than another? At the outset it is certain that what appears to be
the same cause shall occasion different forms of insanity in different
persons and even in the same person at different periods of life, and
that the same form of disorder shall be produced by different causes;
this being so it is plain that the special determining conditions lie
hidden in that unknown region which we call by such names as
‘ temperament ’ and * idiosyncrasy.’ ”

If these questions, which have all these years remained unanswered,
have not been brought nearer a solution by the medical lessons of the war,
the scope of their inquiry has at any rate been broadened. We have
learnt that a uniform group of powerful emotions, coupled in a certain
proportion of cases with unusual strain, can be the exciting cause of the
appearance of the symptoms of both the neuroses and psychoses;
that no new forms of the neuroses or psychoses have been produced as
a result of the war; that war neuroses and psychoses depend in the
majority of cases upon an inborn temperamental neurotic disposition—
in other words that they were not caused, but revealed or accelerated by
war conditions; that neurasthenia and the so-called psycho-neuroses
may pass into definite forms of the psychoses ; that the mode of origin,
course and termination of the war neuroses and psychoses are in the
main similar ; and that the majority of cases of war psychoses have been
successfully treated and tended towards recovery without recourse to the
legal formalities established for the protection of the sane and the insane.

Twenty-five years ago my respected teacher, the late Sir Thomas
Clouston, assumed the identity of the psychoses and the neuroses in his
Morison lectures entitled “ The Neuroses of Development.” The scope
of these lectures embraced epilepsy, hysteria, and his own adolescent
insanity—later on differentiated by Kraepelin into mania-melancholia
and dementia precox.

Clouston emphasised the relationship of the psychoses and neuroses
mainly on the ground of their developmental origin, and did not push
the analogy further. Had his creative mind been earlier directed
to the consideration of the subject he might probably have enunciated
more far-reaching conclusions. To him, however, belongs the merit of
having first proclaimed this identity.

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1920.]

Ten years later I had the privilege of delivering the Morison Lectures
and chose as their title “ Variation in Relation to the Origin of Insanity
and the Allied Neuroses.” The thesis proved sufficient so far as mental
defect and the neuroses were concerned, but when the point was
reached of applying it to the insanities my vision of the problem failed
me. This failure, I now see, was due to the prevailing conception
of the term “disease” as applied to the insanities—a conception which
has never been called in question, although unconsciously we differ¬
entiate its use when we think of different forms of insanity. That is to
say, while we apply the term “ disease ” in an equivalent sense to acute
mania and typhoid fever, we either do not apply it or apply it in a
different sense when we refer to congenital mental defect.

In the ordinary work of our specialty we see, as a rule, only the more
pronounced and advanced forms of mental disorder, which we designate
“ mental disease.” The designation is justifiable in a medical sense so
far as concerns the profound mental and bodily disturbances which
accompany the acute psychoses; but there are milder forms of the
psychoses which never reach mental hospitals and whose symptoms do
not, as a rule, suggest to the lay mind the existence of mental disorder.
The concentration upon one—the more severe—group has certain dis¬
advantages : it prevents a comprehensive and comparative view of the
whole field of morbid psychology; it tends to the setting up of an arti¬
ficial barrier, inside which are the mentally “ diseased ” with their
physicians and attendants, and outside of it the subjects of the unrecog¬
nised psychoses, the medical profession, detached and uninterested, and
the general public, who manifest an instinctive dislike to everything
labelled “ insanity.” The remedy for this state of matters is the educa¬
tion of the medical profession ; but the educators are on one side of the
barrier,and they must as a first step come over and investigate the forms of
mental disorder which undoubtedly exist in the outer world. It is true
that such accomplished authorities as Morel, Pritchard and Maudsley
—to name three out of several—did recognise this outer field of morbid
psychology, but except that they mention mental depression and hallu¬
cinations they refer to its other manifestations vaguely as eccentricity,
immorality, vice, and even genius.

In order to appreciate the extent to which unrecognised mental
disorder exists in the general population one must possess psychiatric
experience and have the opportunity and desire to observe. Given
these conditions it should be possible to detect, almost anywhere,
mental defect, intellectual or moral; the various forms of mild dementia
prsecox or the terminal stages of that disorder; the periodic emotional
oscillations or the recurrence of mild depression or mild exaltation
which characterise manic-depressive insanity; or the unfounded sus¬
picions, the delusions, the aggressiveness and the vindictiveness which

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indicate paranoia. The aberrations of conduct which accompany these
mental disorders are usuallyattributed to moral rather than to pathological
causes. For instance, alcoholic and sexual irregularities are commonly
associated with the exalted phase of the manic-depressive syndrome; in
the depressed or lucid intervals of the disorder the same subjects may
be models of good behaviour. If, however, the pathological condition is
not recognised, misconduct falls to be explained on other grounds. The
aimlessness, the inefficiency and idle habits in the milder forms of
dementia praecox, the incompetence or immorality in mental defect
and the unreasoning aggressiveness in paranoia are all unrecognised
and misinterpreted.

The milder forms insensibly merge, by gradation, into the pronounced
forms, so that at one end of the scale we see conditions unattended by
physical disability, and such a slight degree of mental disturbance that
it escapes recognition and is usually interpreted in terms of moral
conduct, and at the other end conditions which pass into definite
disease in the ordinary medical acceptation of the term.

It is precisely the same with the functional neuroses. Epilepsy and
hysteria may become veritable diseases in the medical sense, yet on the
other hand they frequently reveal themselves as mere episodes in the
useful lives of countless individuals in every generation and every race of
mankind. As in the case of the psychoses the milder forms pass by
gradation into the severer forms which attain to the status of disease.

But neither in the psychoses nor in the neuroses is the “ disease ”
form typical of either group; the clinical aspect of both can be better
appreciated by treating their natural history together. Thus :

(1) They are all markedly hereditary.

(2) The heredity is transformable—neuroses appearing in the ante¬
cedents and collaterals of the subjects of the psychoses and vice vend —
from which we may imply the existence of a common hereditary basis.

(3) They constitute genetic variations from the normal in respect of
a hyper-excitability of the sensori-motor elements of the cerebral cortex,
which renders the subjects susceptible to mental suggestion or to
physical or mental impressions which do not similarly affect normally
stable individuals.

(4) There is present in the majority of the subjects a perceptible
psychical modification more marked during the episodic crises, and which
tends sooner or later towards a varying degree of mental deterioration.

(5) The symptoms exhibit a marked tendency to periodicity,
irregular recurrence, exacerbation, or relapse.

(6) As a rule this tendency to periodicity and recurrence continues
throughout life, but it may weaken in maturer life as the vital and sexual
forces subside.

(7) No anatomical lesion or defect of the nervous system has been

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1920.]

observed upon which a pathology of the functional neuroses or the pure
psychoses can be established.

(8) There is present, at any rate in the severer forms, which alone
have been investigated, certain disturbances of metabolism, of the
blood elements and of the vaso-motor functions, of the causes and
nature of which we are ignorant.

(9) The symptoms usually commence to manifest themselves in early
life—childhood and the adolescent period.

(10) The neuroses and psychoses have no geographical or racial limit
but affect individuals of all human races, and, so far as that is possible,
of several of the higher animal species.

The first six points are so generally admitted that comment is
unnecessary; the last four require further explanation.

If there is no anatomical change in the structure of nerve tissue
characteristic of all phases—mild or severe—of the neuroses and
psychoses, then we have to deal with functional and not organic
disorders.

The published descriptions of secondary or degenerative changes in
the nervous system following upon long-continued recurrent crises or
severe attacks of the characteristic manifestations of the neuroses or
psychoses do not establish a pathology. Neither do the striking
changes in nerve-cells, especially in the acute psychoses, which are
occasionally described, but which more probably result from intercurrent
super-imposed auto-intoxications, carry us any nearer a solution. The
fact remains that in a comparatively large proportion of cases, even
when the crises are frequent and extend over long periods of years,
there have not been discovered such uniform anatomical changes as
would justify a pathology founded upon the morbid anatomy of the
nervous system. This negative evidence does not, however, exclude
the possibility of undetected changes. It might be argued that as the
psychoses and neuroses are hereditary variations their solidarity with
mental defect is more than theoretical. We know that in lower-grade
defectives physical malformations—the outward signs of nervous mal¬
formations—are numerous, and that these malformations become fewer
in the ascending scale of defectives until they finally disappear alto¬
gether in the highest class, in which the only remaining diagnostic
criteria are what we vaguely term mental instability and a tendency to
suffer from one or other of the neuroses or psychoses. We also know
that the nerve-cells of epileptic idiots show certain characteristic
changes, and that in lower grades of mental deficiency certain layers of
cortical cells are less developed than in normal subjects. It is not,
therefore, illegitimate to assume that these, and probably other changes,
extend in a modified degree to the hereditary subjects of the neuroses
and psychoses. Again, we know that in Jacksonian epilepsy certain

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limited groups of cortical cells may acquire an explosive quality, but it
has never been asserted that these cells—which have often been excised
with good results and examined carefully after excision—have exhibited
any perceptible difference from normal cells. Quite recently Sir
Frederick Mott( 2 ) has shown us the changes in certain glands—especially
the testicles—in dementia praecox, and has correlated these with
degenerative changes in the nuclei of the cortical neurons. We await
further information from his indefatigable and illuminating researches.

Whether or not the metabolic disorders which undoubtedly accom¬
pany the severer crises of the psychoses and some of the neuroses are a
constant feature of all phases—mild or severe—of the various groups, or
whether that disorder is primary or secondary, is for the present uncertain.

It is unfortunate that the researches of Dr. Lewis Bruce have
not been followed up. His writings remain our sole guide on this
interesting and important subject. He found that in the acute
phases of dementia praecox and manic-depressive insanity there was
hyper-leucocytosis with an increase of polymorphonuclear cells. A
relapse was generally preceded by a fall in the leucocytosis ; when a
case recovered the leucocytosis remained high for months and even
years; in cases which became chronic or demented the leucocytosis
and the percentage of polymorphonuclear cells fell. Bruce also found
hyper-leucocytosis present in epilepsy, not only during the period of
the seizures but in the intervals between them. Coincident with the
hyper-leucocytosis there was generally a high blood-pressure.

Bruce attributes these phenomena to toxaemia but does not suggest
any special toxin. In some undoubtedly infectious diseases, such as
phthisis and typhoid fever, there is pyrexia without leucocytosis; in the
present instances we see leucocytosis with no—or very slight—pyrexia.
The relation of nervous perturbation to metabolism has yet to be
discovered, but the features mentioned seem to point to secondary
changes the result of some direct disturbance of the nervous mechanism
affecting the secretion of the endocrine glands. In any case it seems
probable that the intoxication is not specific, that it varies in intensity
with the severity of the nervous perturbation, and that its deteriorating
influence on the finer structure of the cortex depends upon the nature of
the toxins, the age of the individual and the resistance of the body tissues.

Although there is no age at which the manifestations of the
characteristic symptoms of the psychoses and the neuroses may not
appear for the first time, the following figures show that in a pre¬
ponderance of all cases they occur before twenty-five years of age :

0-25.

Epilepsy (Gowers).89 ’6 per cent.

Hysteria „.720 „

Mania-melancholia (Kraepelin) . . . 60 0 „

Dementia praecox „ . . . 66 0 ,

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1920.]

BY JOHN MACPHERSON, C.B.

With regard to the psychoses, Thurnam (Statistics of Insanity) and
Kraepelin ( Psychiatrit) agree that the stated age of the development of
the symptoms is misleading, and that probably a much larger proportion
of the casqs should be placed in the earlier period of life (before
twenty-five) than is at present done. The age on admission to hospital
is usually correct, but the duration of the illness prior to admission as
well as the existence of previous symptoms is open to obvious error.

During much the greater part of last century the opinion prevailed
that the neuroses and especially the psychoses were diseases, if not
directly the result of civilisation, at any rate and in some vague manner
augmented and intensified by it. At present a different opinion—that
they are genetic variations—is beginning to find favour, but our faces still
continue to be oriented towards the older view. The following facts,
though not in themselves conclusive, may help towards a decision
between these two views; for it is only reasonable to suppose that dis¬
orders which are a common inheritance of humanity and of some of the
higher animals are neither the phenomena of acquired disease nor the
results of civilisation.

Epilepsy in all its forms is met with in domestic animals, including
fowls and birds. Friedenberger and Frohner( 3 ) divide the disease as it
occurs in domestic animals into idiopathic, symptomatic, traumatic and
reflex epilepsy. They also describe the minor form (petit mat).
“ During the periods between the fits,” they say, “ the animals show all
symptoms of health ; mental depression, cerebral troubles, dulness of
the senses and of the intelligence are rare.”

“ Of all the diseases included in the group of the neuroses,” says
Hirsch ( 4 ), “ none shows a prevalence so general in time and place as
epilepsy ; none is so constantly present in the morbid life of humanity ;
none has so markedly the ubiquitous character.” Epilepsy would
appear to be uninfluenced by climate or soil or race or habits of life.
It is of the same type and generally common in all the races of Europe,
in the Moorish population of Algiers, among the Mongols of Northern
and Southern Asia, among Malays, Javanese, natives of Peru and
Indians of Brazil. In fact, so far as is known, no race in the world is
exempt. Local differences undoubtedly exist in the prevalence of the
disease. These are best obtained from the records of countries which
have military conscription. In France the number of conscripts sent
back on account of epilepsy, from 1831 to 1853, was 6,627 in a total of
4 i° 36,372, or r6 per 1,000; but taking the period 1850 to 1869 it rises
to 2*75 per 1,000. In Italy, out of 2,333,288 recruits medically inspected
in fifteen years, 5,103, or 2 ’4 per 1,000, were rejected on account of
epilepsy. In Belgium the proportion was o’go, and in five districts of
Wurtemberg o'93. In the several provinces of France the proportion
of epilepsy appears to vary irregularly from o - 5 to 3^4 per 1,000. In

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Italy the distribution shows as a general rule that the disease pre¬
dominates in the Southern and Western provinces in contrast to the
North-Eastern.

From these and other sources Hirsch estimates the average frequency
of the disease in Central and Southern Europe at about i'5 per 1,000
inhabitants.

Catalepsy, which in the human subject is frequently an associated
symptom of hysteria, is common in animals. It has been recognised in
the ox, the dog, the horse and the prairie wolf. According to Frieden-
berger and Frohner the symptoms which are analogous to hysteria in
man usually commence suddenly without any precursory indications; in
some cases, however, there is anxiety, excitement or loss of appetite.
The animals are unable to make the slightest voluntary movement;
they remain immobile in the position in which the catalepsy has
surprised them. Muscular resistance and rigidity are at first apparent
but these symptoms gradually pass off. Intelligence is more or less
affected and general sensitiveness is greatly diminished. The attacks
may be repeated and their duration is uncertain, lasting from a few
minutes to a few hours. A peculiar form of balking in horses is
described by Friedenberger and Frohner which may culminate in
veritable mania and is accompanied by serious cerebral symptoms.
This phase of excitement is succeeded by a considerable depression of
strength. Hysteria in the dog may assume extreme forms, and
instances are recorded in which hysterical paresis occurred.

The symptoms of hysteria among primitive peoples are so inextricably
conjoined with alleged demoniacal possession, gifts of prophecy,
religious ceremonies and the practice of the healing art that it is not
always possible to dissociate them.

Tylor ( 5 ) remarks: “ Persons whose constitutional unsoundness in¬
duces morbid manifestations are indeed marked out by nature to
become seers and sorcerers. Among the Patagonians patients seized
with falling sickness or St. Vitus’ dance are at once selected for
magicians and soothsayers. Among Siberian tribes the Shamans select
children liable to convulsions as suitable to be brought up to become
hereditary members of the Cult."

Estimated by its universal diffusion over the world, hysteria must be
the most common of all the neuroses. In the very oldest Brahminical
writings, which precede by thousands of years the Christian era,
mention is made of it among the diseases of the nervous system.(°)
Coming down to modem times, we find it constantly referred to in the
writings of travellers. Judging from the comparative frequency of these
references, we can form the opinion that one of the principal seats of
the malady is the group of countries in the arctic latitudes of the Eastern
Hemisphere, including Iceland, the Faroe Islands, Lapland, and the

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parts of Europe and Asiatic Russia in the extreme north. From these
regions we have information of the truly endemic prevalence of hysteria
among the women of the Samoyeds, of the Yakuts, and other Siberian
tribes, as well as among the inhabitants of Kamtschatka. It is also
unusually common among the women of Samara and the Kirghiz Steppes.
Although hysteria is common enough in Central Europe, it is less so
than in the northern or the southern parts of the Continent, such as the
south of Spain or Italy. Oppenheim, quoted by Hirsch, states that in
Turkey it is “ the heritage of women and the scourge of men.”( 7 ) Dr.
Roser, quoted by Hirsch,( 8 ) states that in Gnadenthal in South Africa
there are few Hottentot women living there who do not suffer from
hysteria in one form or another. The same appears to be true for the
Abyssinian territory bordering on the Red Sea, for parts of Egypt and
for Tunis. On the table-land of Mexico hysteria counts among the
commonest of diseases, and it is frequent in Costa Rica, Brazil, Chili
and Peru. Among the inhabitants of the Malay Peninsula a peculiar
manifestation of the disease, known as “ latah,” is very common. Dr.
Ellis gives an excellent description of it.( 9 ) “ The symptoms in a latah

subject can be suddenly aroused in many different ways, usually trivial
in their nature, such as an unexpected noise, some sudden action on the
part of a bystander, a sudden touch, or the mere mention of some
word—usually the name of a wild animal, such as a tiger. The duration
of the phenomena is variable, and may last from a few moments to half
an hour or more.” Latah is as old as the known history of the Malays.
The sufferers are more frequently females than males, and, though
there are differences of opinion on the point, it is generally held to be
more common among young females. The disease is nearly always
hereditary.

When we turn from endemic to epidemic hysteria we open out an
endless field which is quite beyond the scope of this paper. One refer¬
ence, however, must be made in order to complete the subject. In
Madagascar, in the year 1864, a peculiar epidemic of hysteria occurred
among girls and young married women from fifteen to twenty-five
years of age. The occasion of the outbreak, which began at one point
and spread gradually almost over the whole island, was the profound
sensation caused among the people by the violent death of the king
and the consequent changes in the religion and laws. The morbid
phenomena were almost identical with those of the dancing mania of
the Middle Ages.( 10 )

When we come to inquire into the similar prevalence of insanity the
evidence is much more negative, and although there is no race of men
who are known to be free from it, yet on the whole travellers are in too
many instances silent. It is evident either that the subject does not
interest them or they simply say that they saw no insane people. Hence

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has arisen the mistaken idea that insanity is a product of civilisation,
and that it is rare or unknown among savage or barbarous people. I
collected on another occasion numerous references from the writings of
travellers for the purpose of showing the unfounded nature of the belief
which has arisen on this subject. Dr. Felkin informed me that he had
seen in all some thirty or forty lunatics on the White Nile. He also
saw some maniacs chained. He was the first to tell me a fact, of which
I have since had confirmation from other sources, namely, that the type
of insanity among the African natives is different from that in Europe.
The prevailing form of mania is a short acute kind, lasting only a day
or two, during which the sufferer is driven away to the woods, or volun¬
tarily runs away, returning again in a few days apparently restored in
mind. Idiocy was very common in his experience, and so was suicide.
Thomson, in his book, Through Masailatid, states that he found
insanity very common. The myths and folk stories of the people are
full of reference to it. Those affected by lunacy are driven away from
the habitations of sane people, or are otherwise isolated. He also
found idiocy very common, especially among the dwarfs and albinos,
the latter of whom were numerous, and about the prevalence of mental
defect among them there was no doubt. Captain Cook, in his Voyages,
referring to the South Sea Islanders, says : “ We met with two instances
of persons of disordered mind, the one a man at Owhyhee, and the other
a woman at Oneheeow. It appeared from the particular attention and
respect paid to them that the opinion of their being inspired by the
Divinity, which obtains among most of the nations of the East, is also
received here ” (in the Pacific). ( u )

Ellis, in Polynesian Researches , says: “ Insanity prevailed to a slight
degree, but individuals under the influence met with a very different
kind of treatment. They were supposed to be inspired or possessed
by some god, whom the natives imagined had entered everyone suffer¬
ing under mental abberration. On this account no control was exer¬
cised, but they were treated with the highest respect. They were,
however, avoided,” etc.

Emin Pasha, in his book, Central Africa , says : “Insanity and also
temporary mental aberration are frequent. The latter is treated with
herbal remedies, which effect an immediate cure by means of sleep and
sweating.” ( 12 ) Wilson and Felkin state : “ Temporary madness is pretty
common, and generally lasts for three or four days, but persons thus
afflicted do not become very violent.” ( 13 ) I might go on indefinitely
multiplying extracts from the writings of travellers to the same effect, but
it would serve no additional purpose.

There is another reason why this belief in the immunity of the less
civilised from insanity has obtained currency, and it is because no
qualified person has been at the trouble to investigate the matter.

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BY JOHN MACPHERSON, C.B.

1920.]

About sixteen years ago, however, Prof. Kraepelin, of Munich, went to
Java and analysed the forms of insanity among the natives in one of
the large asylums there.( 14 ) His first inquiry was whether the influence
of climate and other tropical conditions of life modified in any way
the symptoms of mental disease. He found that Europeans born and
reared in Java present exactly the same clinical types of mental
diseases as at home. As to the abuse of stimulants and narcotics,
the natives do not drink alcohol, and there were therefore no cases of
alcoholic insanity among the native population of the asylum. Opium
smoking and abuse of the drug is, however, common, yet no patients
in the asylum owed their insanity to that cause. The same is true of
the large asylum at Singapore, in which city the Chinese population is
notoriously given to the abuse of the drug. Of especial interest also is
the fact that out of 370 insane natives there was not a single case of
general paralysis, whilst among fifty European men who were inmates
of the asylum at the same time there were eight cases. Dementia
praecox was found to be extremely frequent, and, on the whole,
presented similar symptoms to those found among Europeans. On
the other hand, mania-melancholia was rare. Many cases seemed to
bear a resemblance to it, but they were found, on closer observation,
to be distinct and peculiar forms of epileptic or hysterical mania. In
those cases in which there was no doubt in diagnosis, the symptoms
presented several variations from the European type. Especially was
this the case in the depressed form of the mania-melancholia syndrome,
where many of the characteristic symptoms were wholly absent. For
instance, ideas of “sinning” were never expressed, and maniacal
agitation was less developed, and more monotonous, than is usual in
western Europe. The great difficulty experienced in forming a satis¬
factory diagnosis of mental affections in Java was the preponderating
amount of “ amok ” and “ latah ” among the patients. The symptoms
of these semi-hysterical diseases not only formed special clinical groups,
but they appeared also to colour the character of other and distinct
forms of insanity. Latah is the great mental affection of the Malays,
just as hysteria is the corresponding disease par excellence of the
Samoyeds and Kamschatkans and other nations of north-eastern
Europe and northern Asia. Short, quickly-passing hystero-maniacal
attacks, similar to those which Emin Pasha and Felkin describe among
the natives of the Soudan, Kraepelin describes as frequent among the
Malays. This leads to the conclusion that it is not so much a question
of the frequency of insanity as of its type which ought to be the basis
of inquiry when studying its manifestations among peoples widely
separated in development, whether racial or social.

Upon some such basis as the foregoing must rest, for the present,
the argument in favour of regarding the psychoses and neuroses as one

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group. The practical results of the acceptance of the proposition
which I have endeavoured, perhaps too academically, to formulate may
be shortly stated.

The psychical element which underlies, often causes and generally
accompanies the symptoms of the functional neuroses justifies their
inclusion within the domain of psychiatry. The influence of their
inclusion would profoundly modify the present too limited sphere of
psychiatry in this country.

The acceptance of the view of the identity of the psychoses and
neuroses would imply the belief that they share in common an inborn
constitutional defect which is ineradicable and irremediable, of which
the varying crises and the tendency to periodicity and recurrence are
the phenomena. The recognition of this fact would constitute an
advance towards a sounder appreciation of the problem of the nature
of the psychoses. It should also lead to a more comprehensive view of
the whole field of morbid psychology.

The war has demonstrated, what Maudsley long ago indicated, that
one and the same cause may originate in neuropathic persons any of
the various forms of the psychoses or neuroses, depending upon the
particular temperament or idiosyncrasy of the individual. Inimical
causes continue to act in so-called times of peace as in times of war,
with the result that there exists in the general population a mass of
definite and indefinite neurosis and psychosis which is at present
unstudied and disregarded.

An obvious corollary to the views that the neuroses and psychoses
are fundamentally one, and that the psychoses extend far beyond the
limits of legal certification, would be a recognition of the necessity for
the establishment of psychiatric clinics in connection with all medical
schools and in all important populous centres for the relief of suffering,
for the preventive treatment of the neuroses and psychoses, and for the
education of the medical profession in the clinical features of medical
psychology.

A responsibility for the initiation of a propaganda for the formation
of these clinics and for the many other reforms which must follow
upon their establishment is incumbent upon all psychiatrists who have
come to a consciousness of the deficiencies of the present system, and
upon those neurologists who have rendered such valuable service during
the war in the treatment not only of the neuroses but of the psychoses.

(') Pathology of Mind, p. 236.—(*) Brit. Med. Journ., November, 1919.—
(*) Pathology and Therapeutics of Domestic Animals .—( 4 ) Geographical and
Historical Pathology .—( k ) Primitive Culture, ii, p. 132.—(®) Wise Commentary on
Hindu System of Medicine, p. 250.—(*) Geographical and Historical Pathology,
vol. iii, p. 519.—( 8 ) Loc. cit., p. 521.—(’) Journ. Ment. Set., London, 1897, p. 33 -
—( ,0 ) Hirsch, loc. cit., p. 529.—( ll ) Cook's Voyages, vol. iii, p. 131.—('*) Central
Africa, p. 94.—(**) Uganda and Egyptian Soudan .—( 14 ) Centralbl. f. Nervenh.,
Leipzig, July, 1904.

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CHRONIC HALLUCINATORY PSYCHOSIS.

Chronic Hallucinatory Psychosis .( ! ) Robert Hunter Steen,

M.D.Lond., M.R.C.P.Lond., Medical Superintendent, City of
London Mental Hospital, Professor of Psychological Medicine
and Out-Patients’ Physician, King’s College Hospital, London.

For several years past my attention has been directed to a series or
cases in which the principal symptom has been the presence of hallu¬
cinations.

Employing the recognised classifications in use in this country, it has
often been a matter of the greatest difficulty to decide under which head¬
ing individual members of this group should be placed.

As the hallucinations give rise to slight depression some might pos¬
sibly be included under melancholia. In others delusions of persecu¬
tion develop and paranoia might be the provisional diagnosis. Others,
again, might be swept into the wide-spread net of dementia praecox.

This state of affairs cannot be regarded as satisfactory, for, as will be
shown later, they are not truly cases of melancholia, paranoia, dementia
praecox or any other described affection.

It is the purpose of this paper, therefore, to attempt to prove that
there are certain hallucinatory cases which can be grouped together to
form a well-defined clinical entity. This I have called “chronic hallu¬
cinatory psychosis.” The choice of a suitable name is of no small
importance, and the reasons for the selection of this one will be given
as the discussion proceeds.

The main feature of the illness is the presence of hallucinations.
These may be of all the senses, but auditory hallucinations are the most
prominent.

At the beginning the patient may realise that the hallucination is a
morbid phenomenon and unaccountable. He may admit that though
he hears a “ voice ” speaking, there is no one in the flesh actually doing
so. Such a state of affairs may last for years, and possibly, though
rarely, for life, and the subject would not be deemed insane in the
ordinary sense of the word. It is probable, however, that this con¬
dition forms the first stage of the illness, which eventually develops on
definite lines. The patient demands an explanation of the hallucina¬
tions. As none is forthcoming he tries to account for their presence,
and the result is a delusion, and, most frequently, a delusion of
persecution. The point to be noted is that the delusion is a compara¬
tively late arrival and is the logical result of the hallucinations.

Other abnormal mental symptoms in the early stages are, as a rule,
absent. The patient is quiet and orderly. The memory is good, and,

(') A paper read at the Quarterly Meeting of the Medico-Psychological Associa¬
tion on February 24th, 1920.

LXVI. 8

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outside the sphere of influence of the hallucinations, conversation is
rational and little amiss is noticed by the friends.

Before embarking upon a more detailed account it will probably
assist the comprehension of the subject if a few clinical illustrations are
given.

Case i. —M. T—, female, aet. 20, single, no occupation. An aunt was insane.
I was asked to see the patient in the autumn of 1916, as she had been subject to
uncontrollable fits of crying since about Easter, 1916. Though no mention of
hallucinations had been made to me, to the question “ What is the matter?” she
immediately replied that she could hear two voices talking to her “ as clearly as
you are talking to me.” In reply to the question as to the nature of the messages,
she said " Hell ” and " other words too awful to mention." On one occasion she
had seen “ pictures of Gethsemane and other religious pictures.” These were the
only visual hallucinations, and they did not recur. There were no hallucinations
of taste or smell, but she had once the strange sensation “as if someone were
touching the skin of my body." On subsequent occasions more information was
obtained as to the content of the auditory hallucinations. She told me she heard
the voices say : “ Don’t take no notice.” “ Mary, it is Satan talking to you.” “Do
you hear me?” “ You had better kill yourself.” " You’ll be a lunatic before you
are many days older.” When she tried to sing hymns the voice said, “ Oh, shut
up.” On one occasion when I was called away from our interview for a few
minutes I asked her to write down exactly what she heard in my absence, with the
following result: “What do you mean by telling Doctor all 1 have told you?
Mary, why don’t you take any notice of me? Go and see your Dad. Mary, don’t
you hear me. What are you looking at ? Whatever are you writing down all
this just to amuse? You are a wicked cat. You won’t go to Heaven,” etc.
Except for the fits of weeping, there were no other abnormal symptoms, mental or
physical. She was a happy-looking girl, and no one, not even her own parents, had
any suspicion of the presence of hallucinations.

The case was intensively studied and may be recorded more fully on another
occasion, but for the present purpose it will suffice to state that after several inter¬
views the fits of weeping ceased. Each time she came to see me I explained the
hallucinatory nature of the voices, which she accepted, and as time went on she felt
herself more and more able to disregard them. I found, also, that there was a very
severe secret conflict in the life of the girl which was unknown to her family, and
with the confession of this she improved so much that the treatment was discon¬
tinued.

I am very sorry to have to report that since this paper was almost completed,
namely, in last December, the patient has found it necessary to return for treatment.
She states, however, that for three years she was entirely free from hallucinations.
The "voices” have now returned with renewed intensity, and I have been able to
discover that the conflict to which reference has been made was not entirely resolved,
and its re-appearance upon the scene has caused the return of the distressing
symptoms.

Discussion .—It is not easy to put a name to this condition. Hysteria
might be thought of and the fits of weeping might easily be termed
“ hysterical,” but their origin was due, as the patient definitely informed
me, to the annoyance caused by the “ voices.” To call the case one of
hysteria or neurasthenia is really only an abuse of these terms and
merely a cloak for ignorance. My own feeling is that it is a case of
chronic hallucinatory psychosis. She was not insane. She did not
develop any delusions with regard to the voices or herself. She quite
realised that these were abnormal. It is for this reason that I have
adopted the word “psychosis” instead of “ insanity.” I would not like

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BY ROBERT HUNTER STEEN, M.D.

IOI

1920.]

to hazard an opinion as to what is in store in the future for this patient.
The French call the condition “ halhicinose" and the majority seem to
hold the view that these cases eventually develop delusions. An illustra¬
tion of this is given as Case 3-(*)

Case 2 is similar in many respects to case i, but is of a more severe
type.

S. S.—, female, at. 38, married, no children. Father suffered from senile insanity.
A half-brother committed suicide. In June, 1914, she fell down the stairs of a motor-
bus and was much shaken. After this she suffered from sleeplessness. About
August, 1914, she and her husband went to live at some flats. The rooms were
close together and she thought she could hear the people talking to each other.
For example, one night she thought she heard one man say to another," What the
devil did he mean by frightening me about motors.” Owing to her nervous
condition they left the flat and went to Maidenhead, and then to another address.
Here she was "delirious” she said. No one knew, however, that she was
" delirious.” By this expression she meant that she could hear “ music in her head
and gramophones talking three or four together. It was like Hell.” The
hallucinations had existed in much the same condition, some days slightly better
and other days slightly worse, till she came to see me in July, 1918. She then gave
a full account of the numerous "voices” she heard. I asked were the voices
imaginary and she replied," I know they are not real, but they are so persistent I
cannot think of anything else.” She was unable to offer any explanation of them.
What led to our interview was the fear that she might lose control of herself.
For example, a voice told her to warn the police that there was a foreigner in the
village she was then living in and she was afraid she might do so. She was
anxious for institutional treatment and at her own request she was certified. She
came to the City of London Mental Hospital, where she was given full parole and
worked on the farm and for a time the hallucinations almost ceased. She had a
slight injury to her foot, and during the enforced rest the hallucinations returned
with increased intensity, and now the chicken and ducks began to speak to her.
She left on trial on November 30th, 1918, not really any better. At the present
time (November, 1919) she complains of severe pain on the left side of the head,
"just like an abscess.” When the sounds come up to the left ear it seems to
cause an awful throbbing. The voices are almost continuous. When asked to
repeat some of the actual words she hears she says, "A boy’s voice has just said
• Some of the dirty little donkeys couldn’t find it out,’ and ' Who would think I
should come down here to make such an enemy as this.”’ The second sentence
was said by a boy’s voice a long way off. Birds and animals appear to talk
to her. For example she says, “ Yesterday the birds said they were sorry they
could not get me into the best society.” She was at a public procession a few
days ago, and a horse appeared to speak quite distinctly to her. A fresh pheno¬
menon is that every movement made by people seems to result in a voice speaking
to her. In order to find out if any delusions were being formed I asked her again
what wa* her explanation of all this. She said, " It’s a nervous thing, a most
mysterious thing.” She admitted that though other people were with her, she
alone hears these different noises. The nearest approach to a delusional inter¬
pretation was her question, " Do you think Mr. Maskelyne could cause all this
by putting me under his influence?” The hallucinations started in the left
ear, then affected both ears, and now again are chiefly in the left ear. There
have been no hallucinations of the other senses. She lives at home and engages in

( a ) As at the time I first saw this patient I was unacquainted with this variety of
illness, I had considerable anxiety as to whether I should recommend that she
should be sent to a mental hospital or not, more especially as the voice once said,
" Kill yourself." She had, however, either to remain at home or be certified—there
was no other alternative—and 1 am now glad I stuck to my guns and kept her at
home. What a case, however, for a psychiatric clinic! May these institutions
soon come!

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her housework, but is easily tired on account of the continual struggle with the
“ voices.” Her friends notice little the matter with her except her preoccupied
expression. She says, “ I have two heads. I have a very sensible head, and yet
you would be surprised at what is going on in the other head." The “ sensible
head” enables her to keep up appearances. This spontaneous expression is
very interesting as indicating that the patient herself has a feeling of dissociation.

Discussion. Here, then, is a patient with auditory hallucinations
which have been in existence for over five years. It is a worse case
than No. i owing to the almost continuous presence of hallucinations.
I am afraid she is beginning to seek for some explanation, which, later
on, may found a delusional system. Except for the severe pain in the
head and the occasional absent-mindedness there are no other mental
or physical symptoms. She converses naturally and rationally on other
topics. At times she looks slightly worried and depressed, but mostly
she is bright and cheerful. She eats and sleeps well.

As regards diagnosis, the remarks made about Case i apply equally
here. As regards causation, one must note the accident. A prolonged
examination into the history of her life has revealed several severe
conflicts, and the investigation is being continued.

The next illustration is taken from French literature. For the
purposes of reference I shall call it Case 3. The following is the
translation of a report ( 3 ) of a meeting of the Psychiatric Society of
Paris held on June 15th, 1911.

M. Seglas said:“ I shall take advantage of the present occasion to give a brief
summary of a new case, the full history of which I shall publish in detail later on.
It is that of a female, aet. 35, who has been tormented for the last five years by
‘voices.’ These ‘voices’ are heard in different ways. Sometimes they speak
‘ mutely ' to use the actual word of the patient. This is the well-known symptom
of ‘ inward voices ’ (voix interieures). Sometimes, on the contrary, they seem to
come from the external world, as though someone were speaking loudly, or more
often with a whispering sound drawing gradually closer to the patient. This
discrimination, quite a spontaneous one on the part of the subject, is very impor¬
tant, for it seems clearly to prove in the second variety the existence of halluci¬
nations properly so-called which are exteriorised. The patient adds that then the
voice appears to come from around her, sometimes from the right side, sometimes
from the left, sometimes from below, just as if the speaker were lying down at her
feet on the floor.

“ At the same time she experiences what has been called the sense of a ‘presence,’
and often also, when the voire approaches to speak in her ear, she feels the
grazing of the actual contact of a body leaning on her shoulder. This sensation
of contact can be produced as an isolated symptom. It can also be exaggerated
as the feeling of a ‘ pushing.’ At other times she feels in her limbs, as it were, a
‘ trifouillage ’ ( 4 ), which forces her to execute strange movements . . . This

condition has lasted for five years without the patient being able to decide as to
the nature of these ‘ voices ’ of hers. She does not at all realise their subjective
character and will not admit that they come from herself, as they annoy her so
much at the time as to make her angry. On the other hand she does not know
what can produce them, and her ignorance in this respect is well expressed in the
neuter designation which she uses : ‘ It speaks to me.’ She has not built up any
system of interpretation regarding them, and even appears much astonished at all

( 8 ) Encephalr, vol. ii, 1911, p. 157.
( 4 ) Untranslatable.

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the questions she is asked in this connection. She only repeats that she has many
times asked the ‘ voice' what it all meant and that she has never obtained any
reply but this, in my opinion a very characteristic one—‘ Mystery ! Mystery I ’

" As I have already had occasion to remark, and as M. Buvat has just reminded
you, patients of this kind are to be kept distinct in our minds from those who are
consciously hallucinated—that is to say, those who of themselves realise the
subjective character of their hallucinations. They are also to be kept distinct, on
account of the poverty or even the absence of any attempt at systematic interpreta¬
tion, from the systematic hallucinated insane. However, the character, the con¬
tents and the evolution of their hallucinations seem rather to bring them in near
relation to these latter, to which they are in all probability closely connected by
a series of intermediary cases.”

To those interested in the subject two similar cases will be found in
Annales Medico Psychologies, vol. ix, 1909, p. 256.

Case 4.— This is also from the French, and was brought before the
Society of Psychiatry of Paris in November, 1911, by MM. Louis
Boudon and Pierre Kahn.

" Mme. F—, a:t. 44 years, has shown signs of hallucinations for three years.
Auditory, olfactory, visual, and those of general sensibility have appeared in her
in succession.

“ For more than two years, as M M. Duprt: and Gelma have said in this place, she
remained simply an hallucinated person without any delusional idea. But at the
present time the clinical picture has changed : delusional ideas have been added to
the hallucinations.

"Present condition : Auditory hallucinations. —These do not allow the patient
any peace. Sometimes she hears things of no consequence; most frequently,
however, there are insults or menaces. People reproach her with not loving her
children, with having had sexual relations with a Protestant or with having had
abnormal relations with her husband. They whisper to her villainous things.
Certain hallucinations of an imperative character order her not to rise up from bed,
not to eat, and not to dress herself.

“ Some antagonistic hallucinations advise her not to be uneasy in mind, telling
her she is a well-conducted woman. But in spite of all that ‘it is unbearable to be
incessantly insulted.’

“ Hallucinations of taste and of smell. —Our patient does not admit any hallucina¬
tions of taste, but she has olfactory hallucinations,and these are generally combined
with those of hearing.

" Hallucinations of general insensibility. —These consist in sensations of formi¬
cation, of tearing and of ' picotements.' These the patient herself often calls by
the name of ‘ crepillements.’

“ Genital hallucinations. —F— complains that persons make her submit to
touchings of the parts.

" Visual hallucinations. —In the evening at nightfall, but sometimes also in the
daytime, F— again sees people that she has seen on preceding days; occasionally
they appear to her ‘as in a cinematograph,’ and when her husband has gone out
she sees him as if he were with her paying visits to the tradesmen of the district.

“ Psychomotor hallucinations. —F— complains that people make her execute
movements in spite of herself, and that they compel her to speak.

“ Our patient then is still badly hallucinated. But at the present time the
symptomatology she has presented for some months past is enriched by new
elements which are—

“ First: Delusional interpretations. —It is the neighbours who insult F— because,
she says, she one day refused an invitation addressed to her by one of them. It
is a gentleman whose name she does not know who reproaches her with having
had certain relations with a Protestant. It is tglantinards and freemasons who
speak to her.

" People magnetise her. One of the physicians who formerly attended her
magnetised her while auscultating her. People have some scientific means by which

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they can make her hear voices at a distance. In the same way, if, while alone, she
sees people she knows, it is that these persons have been given a certain power
( fluide grdce) by which they can reappear before her. We have not ascertained
any ideas of grandeur.

“ Second : Neologisms. —Not numerous, but among others you will remember the
word ‘ crepillements' by which F— names certain of her hallucinations of general
sensibility.

" Third : Reactions in opposition to her persecutors. —These have diminished to
a great extent.

“ However, F— answers the insults that she hears and often gets angry. She has
told us of her intention to change her residence when she leaves the asylum. She
requested her husband to lodge a complaint at the police station against her
persecutors.

“ Lastly, she has come to us hoping that physicians would be able to instruct her
as to the proper scientific means to thwart those of her enemies.”

It may be as well to pause here for a moment to review the ground
covered so far. The first case is that of a patient who was completely
aware of the abnormal character of the hallucinations. The second
is of a more severe type. The patient had at first distinct insight as
regards her condition, and for many years has been able to live among
her neighbours without their noticing anything amiss, but she is now
beginning to lose touch with her environment and is afraid of herself.
Delusions seem to be on the point of developing. The third patient
has not developed delusions, but has no insight of the nature of her
illness. Case No. 4 is one in which definite delusions have developed
in a person who for many years had hallucinations only.

The following and last case is an example of the same sequence in
one of my own patients. I have selected this one as she has been
under observation for some time.

Case 5.— C. N. C — .female. Admitted to the City of London Mental Hospital,
January 6th, 1915. Single; governess. Father alcoholic. Father’s brother
died insane. One sister insane, a second sister unstable, a brother died insane,
another brother died from alcoholic excess, another brother had a drug habit.
Father and mother are dead, and she had been living quietly with a sister at
D—, going out as a daily governess.

In the summer of 1912 a brother, F. C. C—, to whom she was very attached,
was missing for several weeks. She and her sister were daily expecting his
arrival, and no news was received from him. As far as can be ascertained he was
in trouble with the police, and shortly afterwards fled the country. While in this
state of anxiety, in September, 1912, she consulted Dr. D— about a small growth
in her gum, and continued going to see him for about two months. Shortly after
her first visit to Dr. D— she began to hear “ voices.” At first she thought it was
his voice. About the same time she commenced to have strange sexual feelings
which she attributed to Dr. D—. The hallucinations continued during the winter
and spring, and in the summer of 1913 she went to some relatives at F— and
the voices were not so persistent as at home, but it was here that " nasty words "
began to come—“ such nasty words.” She gave up teaching during this summer,
but resumed this in the winter, and finally ceased her work in August, 1914.
About this time, also, it seemed as if “ thoughts ” came to her from other people,
and that other people could read her thoughts. In November, 1914, she had the
visual hallucination of seeing Dr. D—. To use her own words, " Quite plainly
I could see his presence beside me. I Was talking to my sister one night and not
even thinking about him, when his presence seemed to be standing quite close to
me.”

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Condition on admission .—She was a quiet, lady-like patient, and conversed in
a natural manner and rationally. Her memory was excellent. I asked her to
write down the actual words she heard, and she gave me two closely-written sheets
of notepaper, too long to quote, but containing, amongst others, the following
words: 11 Eternal weary man,” “Too rummy,” "Too guarded,” "Can’t beat it,”
“ Booby,” “ Get thinner,” “Unhealthy yet married,” "Tea,” “Cursed in spite,”
"Hoodwink.” “Beat her, bruise her,” etc. She had also the “ echo’’-sensation
of hearing her thoughts spoken aloud. There were no hallucinations of the other
special senses. Besides the hallucinations she complained bitterly of the sexual
feelings.

During the last five years there has been but little real change, though she is at
times worse than others. Mostly she is industrious, but at other times refrains
from all work, as it does not seem to further her discharge. At first she could offer
no explanation of the hallucinations, but she has now formed the delusion that she
is being persecuted by some unknown agency. She is seclusive and rather avoids
myself, as she thinks I ought to take active measures to stop this persecution.( J )

It is interesting to note that a sister, who is still engaged in teaching, and whom
no one seems to suspect of being mentally affected, as long as three and a-half
years ago told me that she heard my voice talking to her all the way in the train
as she was travelling up to London.

Discussion. —Here, then, is a patient who, since 19x2, has been the
subject of auditory hallucinations. Arising from these, delusions of
persecution have developed in a logical manner. These delusions are
vague, and have appeared only as a late symptom, and there are no
signs of dementia.

The illness came on after a period of severe anxiety. About the
same time she consulted a doctor whom she fell in love with. Her
symptoms and the analysis of her dreams clearly proved this to be the
case. Both the disgrace of her brother and her love for the doctor
were strongly repressed, and, to my mind, this repression caused the
auditory hallucinations. This, however, is another matter which will
be considered later when the aetiology of the disease comes under
discussion.

The point we are most concerned with at present is—“ What is the
diagnosis ? ” The seclusiveness suggests dementia praecox. Against
this there are absolutely no other signs or symptoms of this disease.
The predominance of the hallucinations rules out paranoia.

A systematic description may now be attempted. This will be made
as brief as possible. Some amount of repetition will be unavoidable
and, it is hoped, will be excused.

/Etiology .—In most cases a careful research into the family history
will reveal a strong hereditary tendency to nervous instability. This is
particularly well marked in Case 5. A statistical inquiry at this stage
is premature, as the numbers known to any single observer are few.
It is not to be inferred, however, that it is a rare disorder, for I can
select half-a-dozen or more with the greatest ease from my own practice.
Without statistics, then, my general impression is that the affection is

( s ) This patient now complains that she hears "silent voices”—her own expres¬
sion. Compare Case 3.

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106 CHRONIC HALLUCINATORY PSYCHOSIS, [April,

one of adult life and begins mostly between the ages of thirty and fifty.
Most of my patients have been women, and it is more frequently met
with in the private than the rate-paid class.

Other observers have suggested that an illness such as pneumonia
may act as a predisposing cause. Such, however, has not been my
experience. As regards the actual cause, it may be noted that a history
of physical injury is often met with. In Case i, for example, she dated
all her troubles from the time when some fire-irons fell on her ankles.
In Case 2, it will be remembered, the patient fell down the stairs of a
bus. Though a physical trauma may play some part as a precipitating
factor, I feel that the main cause is psychical. In all cases which I
have studied intensively, I have found evidence of severe mental
conflict with more or less repression of the same.

Pathology .—There is no known special morbid anatomy. Not one
of my cases has died, and other observers have published no accounts
of post-mortem examinations so far as I am aware.

The conception of the real nature of the illness will depend on the
theory of hallucinations in general. Such a theme would suffice for
many papers. Though the following statement sounds dogmatic I
hope it will be forgiven, as in the interests of brevity I have tried to
make it as concise as possible.

There are many theories with regard to hallucinations founded on a
material conception, and so far no centrifugal, centripetal or special
centre theory has met with general acceptance or advanced our
knowledge in the least degree.

The nature of the phenomenon can be best understood if approached
from the purely psychical side. An hallucination is the result of
dissociation of the mind. As to what is meant by this, the following
examples may be given : When a man reads aloud and his thoughts
wander to other matters there is a small amount of dissociation. A
greater degree is met with in automatic writing. Other examples could
be given showing increasing severity till the extreme limit of the
multiple personality is reached. In chronic hallucinatory psychosis
dissociation of the mind has taken place. This dissociation has been
caused by mental conflict more or less repressed in a person con¬
genitally mentally unstable. It is noteworthy that the patient may
possibly have a feeling of dissociation. An example of this has been
given in Case 2.

Symptoms and course .—After a period of some mental uneasiness,
and possibly sleeplessness, an auditory hallucination appears with
startling suddenness. The patient is naturally astounded. Other
auditory hallucinations follow rapidly and cause a certain amount of
distress. At first it is admitted that these hallucinations are “ imagi¬
nary ” or "not real.” These are the expressions used by the sufferers

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1920 .]

BY ROBERT HUNTER STEEN, M.D.

107

themselves, and though, strictly speaking, not very accurate ones, they
convey to our minds the fact that the patient realises he is dealing with
something abnormal in his personality. At a later stage he abandons
the position that the voices are subjective and states that they are
produced externally by some unknown agency. In a word, insight is
now at an end. The final stage is, that the unknown agency is now
known, and consists of “freemasonry,” “ wireless telephony,” “a gang
of persecutors,” etc., and the patient is now the subject of hallucinations
plus delusions. The delusions, moreover, are the logical product of
the hallucinations. The hallucinations do not differ in any marked
manner from those met with in order forms of insanity. They may be
of all the senses, and auditory are most frequent, visual least so. One
very painful feature is that the voices convey messages of an obscene
or blasphemous nature. With regard to the sensation of touch, a
symptom which causes intense distress is the hallucination that the
genital area is being touched or interfered with. A strange hallucina¬
tion is that of someone being present in the room—not seen, or heard,
or felt, but just a feeling as if there were a “presence ” near. In some
cases the hallucinations may be continuous while the patient is awake.
They cease during sleep, but immediately reappear on awakening either
in the middle of the night or in the morning. Sleeplessness is not a
prominent symptom except in the later stages of the disorder.

During the first part of the illness, for many months, or even years,
other mental symptoms are absent. The general behaviour in no way
attracts attention. The expression is normal, conversation is quiet,
rational, and without loquacity or retardation. The memory is excellent,
emotional excitement rare and depression only slight. In short,
outside the sphere of influence of the hallucinations there is nothing
that can be taken exception to. Later on, as the hallucinations with
their delusions assume the control of the personality, many symptoms
arise. The expression becomes anxious. A listening attitude may be
adopted and the “ voices ” may be conversed with. Memory for recent
events may be poor, because the attention is distracted. Conversation
is to a considerable extent confined to the hallucinations and delusions.
Letters may be written to the Home Secretary or other important
personages. The police are asked why they do not interfere to stop
the persecution. Violence may be threatened and suicide suggested.
The extent and severity of these symptoms will depend on the hold the
delusional system has obtained. This may be put in other words,
using the illustration of Case 2, who said that her mind was divided
into two parts—a “ sensible ” and a “ bad ” one. At the beginning the
“sensible” part is by far the larger and can easily control the aber¬
rations of its fellow, but as time goes on the former shrinks pari passu
with the increase of the latter and the symptoms mentioned appear.

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108 CHRONIC HALLUCINATORY PSYCHOSIS, [April,

The whole process is very gradual, hence the name “chronic.” It is
not strictly continuous, as there are periods of remission and exacer¬
bation, with again subsidence, but viewing the illness as a whole it
steadily increases in intensity. Having reached its maximum, the
severity of which varies in different subjects, the condition remains
stationary for years. Possibly I have not observed the cases for a
sufficiently long time, but I have not seen the development of delusions
of grandeur followed by dementia as described by some authors.

Diagnosis .—Hallucinations occur in all forms of mental disease and
are probably the commonest symptoms met with. It is therefore
evident that the mere presence of hallucinations will not suffice for
diagnosis. In chronic hallucinatory psychosis, however, the disorder
begins with hallucinations, and the patient outside the sphere of these
appears to be normal, so that in the early stages the diagnosis will be
simple. In the later stages, this will have to depend to some extent
upon the history of the illness and may not be so easy a matter. But
if the delusions appear to be the logical outcome of hallucinations which
have preceded them, and that if outside the diseased area composed of
hallucinations and delusions the patient appears but little abnormal, the
diagnosis will be made.

Differential diagnosis .—If these main points are remembered there will
be little difficulty in excluding general paralysis, the manic-depressive
group, true melancholia and the secondary and organic dementias.
Neither need acute confusional insanity, also called acute hallucinatory
insanity, detain us as it is altogether different. Chronic hallucinatory
insanity of alcoholic origin has many points of resemblance to the dis¬
order under discussion, but in the former there is a history of alcoholic
excess for a long period, in the latter this is wanting. Moreover, in the
alcoholic, the delusions of persecution are more pronounced and appear
at the same time as the hallucinations.

In practice, however, the temptation will be to include the cases we
have been considering under the heading of dementia praecox, or paranoia.

To take dementia praecox first. No doubt many cases similar to
those I have described have been squeezed into this category because
there was no other place for them. It has ever been the bane of our
specialty that it has suffered from nosological fashions. When a certain
clinical entity looms largely before the eyes of the practitioner it becomes
the universal disease. To-day it is dementia praecox, and I think it will
be admitted by all that we have to be constantly on our guard so that
we do not diagnose dementia praecox in cases which our present
ignorance should urge us to deem as unclassifiable. There are really
very few points of resemblance between chronic hallucinatory psychosis,
as I understand it, and dementia praecox. It is true that in the para-
noidal form there may be delusions of persecution with hallucinations.

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1920 .]

BY ROBERT HUNTER STEEN, M.D.

109

But these delusions are not systematised nor are they the logical outcome
of the hallucinations. They are constantly changing and have that
“freaky” character common to dementia praecox. Furthermore, a
typical case of this latter disease with its emotional apathy, lack of
judgment, scattered ideation, and all the peculiar behaviour such as
impulsiveness, negativism, stereotypy, mannerisms, monkey tricks and
the rest, bears no resemblance to one of chronic hallucinatory psychosis.

Lastly there is the question of paranoia, and this cannot be dismissed
so summarily. In both paranoia and chronic hallucinatory psychosis
the beginnings of the illness may be unnoticed for years by the friends
of the patient, the evolution is slow and gradual, and outside the sphere
of the disorder the patient is well conducted, collected and rational in
conversation. In neither, even after long periods of time, does dementia
supervene. There is, however, this great distinguishing feature—that
paranoia is characterised by the absence of hallucinations, and in chronic
hallucinatory psychosis the presence of hallucinations is the main sym¬
ptom. I could give numbers of references from various writers to show
that they regard almost as pathognomonic of paranoia the fact that
hallucinations are absent. Perhaps one will suffice : Kraepelin, in dis¬
cussing the differential diagnosis of genuine paranoia and dementia
praecox, states that the former do not suffer from hallucinations^ 8 )

Someone may say, “Why not call this new disease ‘hallucinatory
paranoia’?” and in some ways such a course would be plausible, but it
seems to me contradictory to set out to describe an hallucinatory form
of a disease which is characterised by the lack of hallucinations.

Before concluding the differential diagnosis reference must be made
to descriptions given by various authors of disorders which more or less
resemble chronic hallucinatory psychosis.

From a large list I have selected the following three :

First of all must be mentioned the Lasegue-Falret syndrome, which
dates from the middle of last century. This consists, to put it very
briefly, of four stages. In the first, delusional interpretation of the
environment occurs; in the second stage hallucinations develop;
in the third stage disturbances of general sensibility arise; and the
fourth stage is characterised by the formation of delusions of grandeur.

Later on came Magnan with his description of dilire cltronique
This, like the last, has four stages also: First stage —suspicion of
the environment with delusions; second stage —hallucinations with
systematisation of the delusions; third stage —delusions of grandeur;
fourth stage —terminal dementia. Most writers agree that a typical
example of Magnan’s disease is rarely seen, and regard it more as a
schema to which various cases approximate more or less accurately.

(®) Dementia Pracox, Kraepelin, translated by R. Mary Barclay, p. 276.

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IIO CHRONIC HALLUCINATORY PSYCHOSIS. [April,

Finally mention must be made of Kraepelin’s paraphrenia, a full
account of which is given as the terminal chapter of Dr. Mary Barclay’s
translation of Kraepelin’s dementia praecox. This conception seems to
be founded largely on Magnan’s dilire chronique , which it resembles in
many respects.

Timfe does not permit of a detailed differential diagnosis of these
from chronic hallucinatory psychosis.( 7 ) It will, however, have been
noticed that in them delusions of persecution form the main feature of
the illness and that these delusions appear prior to the appearance of
the hallucinations, whereas in chronic hallucinatory psychosis the
reverse is the case. Furthermore, in the latter delusions of grandeur
and terminal dementia do not occur.

Prognosis .—The earlier the case is seen the more hopeful is the
outlook. After the development of delusions little can be done to
avert chronicity. The general health is not affected and there appears
to be no danger of terminal dementia.

Treatment .—In the early stages benefit is sometimes obtained by
change of environment. Rest from work, freedom from anxiety and
change of air and scene should be advised ; these measures, with plenty
of nourishing food, relief of constipation if present, tonics and an occa¬
sional hypnotic to ensure sleep may do good in some cases. I have
not much faith in the efficacy of any particular drug to remove hallu¬
cinations. Small doses of the bromides or hydrobromic acid have been
recommended. If the patient does not improve under this treatment a
thorough mental examination must be undertaken. This will, almost
certainly, reveal a conflict, which, with repression of the same, is causing
the dissociation. Even then the work may not be at an end and a
psycho-analysis will be necessary. The difficulty at the present time is
to get in touch with the patient in the primary stage. Even now, how¬
ever, some do come to the mental out-patient departments of the large
hospitals and in the future many more will be met with in the clinics.
When the patient reaches the stage when he has to be certified the
whole morbid state has become so fixed as to be little affected by
analysis in the majority of cases. Even then, however, this should be
undertaken with a view to the study of the mechanism of the process.
If it be generally confirmed that dissociation is the pathology of the
condition then we might expect that hypnosis would be beneficial, seeing
that Morton Prince produced recovery in the classical case of Miss
Beauchamp (a dissociated personality) by this means. On this matter
I cannot speak from personal experience.

(!) This matter is discussed in considerable detail in a paper by Roxo on “ D^lire
Systematise Hallucinatoire Chronique,” read at the International Congress of
Medicine in London, 1913, and published in the Transactions, section " Psy¬
chiatry,” Part II, p. 104.

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1920 .]

HEAD INJURIES IN PSYCHOSES.

I I I

When the condition has become chronic little can be done save to
treat the patient on general lines, and by means of suitable occupation
to prevent him from becoming worse.

In conclusion, I would venture to suggest that the subject of the
hallucinatory insanities should receive more attention in England in the
future than has been the case in the past. If the medical journals of
other countries, notably those of France, are studied numerous papers
and discussions on these matters will be found in them, and yet in this
country they are rarely mentioned. The subject is undoubtedly a diffi¬
cult one, but it appears to me that out of the mass of somewhat con¬
fusing material the disorder I have tried to describe can be separated
as a definite clinical entity. It may seem to some a matter of indifference
what nomenclature is adopted. This, however, to my mind is most
important, for with recognition and naming come investigation on
definite lines.

I am therefore expressing the hope that others will follow suit on the
same lines, and that by additional intensive study many gaps in my
description will be filled in, and that eventually with timely recognition
early treatment may lead many patients to recovery.

Head Injuries in Relation to the Psychoses and Psycho-neuroses.( l )
By Richard Eager, O.B.E., M.D.Aberd., Senior Assistant
Medical Officer and Deputy Medical Superintendent, The Devon
Mental Hospital, Exminster; late Officer in Charge of The Mental
Division, The Lord Derby War Hospital, Warrington.

Until the outbreak of hostilities in August, 1914, the number of
cases of mental disorder associated with head injury investigated by
any one individual must of necessity have been very small. Hence the
sparcity of literature on this subject. Never before the outbreak of the
late war have so many men been engaged in armed conflict against one
another, and never before have arms of such a destructive kind been
employed.

Comparatively suddenly, therefore, we are brought face to face with
a large number of men receiving terrible injuries to the skull and its
contents, the like of which has never before been known. Thanks to
the high standard of efficiency of modern surgical methods a large
number of these cases have been restored to a condition fitting them to
become useful citizens, but on the other hand the ultimate condition of
some has not been such a favourable one, and it is with regard to these
cases that I am confining my remarks in this article.

For a period of two years, during which I was in charge of the
Mental Division, comprising 1,000 beds, at The Lord Derby War

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I 12 HEAD INJURIES IN PSYCHOSES, [April,

Hospital, I have kept personal records and observations on all cases
with head injury that were admitted, and it is from the study of this
collection of cases that the following observations have been made.

In reviewing the cases of head injury met with surgically by Lieut.-Col.
Gordon Holmes and Lieut.-Col. P. Sargent up till September, 1916,
they stated that the proportion of cases in which insanity or epilepsy
had developed was surprisingly small.(i) They state that many patients
presented symptoms of dulness, loss of memory, irritability and childish¬
ness during the early stages, but in the majority of cases these symptoms
disappeared or diminished. That during a period of twelve months
only eight patients who were wounded in the head were admitted to the
Napsbury War Hospital as mental cases, and four of these had since
been discharged. Of the four others one had been previously invalided
from the army for mental trouble but had re-enlisted, a second was
considered to be a case of dementia praecox, and in the two remaining
cases only were the persistent mental symptoms attributable to the
head injury.

Cecil A. Joll (2), from a series of twenty cases, states that two cases—
both French—showed “ mental instability.” One of these was a case of
cerebral abscess following shrapnel wound penetrating the left parietal
region, and the other a glancing bullet-wound of the left parietal region.
There were also two cases with symptoms of delirium—one of these
a German with shrapnel wound of the right side of the fronto-parietal
and occipital regions, and the other a Frenchman with a glancing bullet-
wound of the right parietal region near the vertex. A sixth case, a
Frenchman with a glancing bullet-wound in the posterior parietal
region, showed maniacal symptoms, and another case was hopelessly
demented.

Such information as the above is too scanty, and based on an
insufficiently large amount of material to be of much value. I think,
however, that by making an analysis of the first hundred consecutive
cases of head injury in which mental symptoms had manifested them¬
selves, and therefore led them to be placed under special observation,
we shall find points of interest to the alienist.

No case was considered by me as a suitable case to include in these
observations unless there was clear evidence that a definite head injury
had been received. All cases therefore which gave “a history” of
head injury which could not be corroborated by examination or
accompanying notes were carefully excluded from my series. Most of
us who have inquired very deeply into the personal histories of our
patients will be familiar with the frequency with which one obtains
vague accounts of alleged head injuries as an endeavour to account for
the mental symptoms, and nothing could be gained by inclusion of such
cases in this record.

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PRINCETON UNIVERSITY

BY RICHARD EAGER, M.D.

1920.]

113

A large proportion of the cases from which the material for this
article was obtained had injuries of a very definitely severe and terrible
nature. They were all taken from a series of over 5,000 cases of war
psychoses that have now passed through my hands during the same
period.

These cases will now occupy our attention, and individual case-
records will be quoted as freely as space will permit.

In classifying head injuries Purves Stewart (3) divides them into
(1) tangential, (2) penetrating, (3) perforating, but for the purpose of
this paper I have divided my cases into “ superficial ” and “ deep.”
By the former I mean, and have included, cases in which after thorough
examination nothing more than a superficial wound involving skin or
subcutaneous tissues was found. In the latter class I have included
any cases where there was injury to the skull or underlying structures.

The table shows the 100 cases accounted for in the above manner,
and grouped together according to their symptoms and the topographical
distribution of the injury.

It is seen that practically half the injuries were of the superficial
character, and in the other half the skull or underlying structures were
involved in the injury. On looking further into these cases it was
also found that 50 were left-sided injuries, 35 were right-sided, and
the remaining 15 were confined more or less to the middle line or else
involved both sides of the skull.

There is at first sight seen to be a striking conformity between the
superficial and deep injuries with regard to the type of cases presented
in each group. There was in fact no marked disproportion of cases in
either with the exception of the epileptics. Here, however, we find
that 12 out of 15 cases occurred in the injuries involving the skull
or underlying structures. In other words, whereas the cases of epilepsy
represent 15 per cent, of the total number of cases investigated, the
incidence of epilepsy was four times greater in the cases with gross
cranial injury than in the cases in which the injury was of a superficial
character. In one of the cases included in the latter group also it
should be mentioned that it was elicited that the patient had had fits
prior to enlistment. Sargent and Holmes, who made investigations into
cases of head injury in a much earlier stage than those included in this
article, mentioned the comparative rarity of epileptic seizures following
head wounds. They found that fits had occurred only in 6 per cent, of
the cases.

On looking further into the figures in the table it will be seen that
the cases of dementia praecox and organic dementia, of each of which
there were two representatives, all figure amongst the deep injuries.

One of the former had been two years in an asylum prior to joining
the Army, and had received his head injury when a child. The other

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PRINCETON UNIVERSITY

Table showing the Cases Grouped according to their Symptoms and Topographical Distribution of the Injury.

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PRINCETON UNIVERSITY

1920.] BY RICHARD EAGER, M.D. I 15

had received a bullet-wound of the mastoid region of the skull in
action, and had had the bullet removed by operation, but being a
Canadian no accurate account of his previous history could be obtained
from any relatives, and during the three months that he was under
observation awaiting repatriation it was quite impossible to obtain
any reliable information from the patient himself. He could not even
give his home address, and frequently was altogether mute in response
to questions, but sat muttering a great deal to himself, and occasionally
bursting out into senseless laughter. He was also catatonic, and
presented most of the symptoms of dementia praecox. Capt. H. J.
Norman (4) has previously described a case in which the symptoms
of “dementia priecox” developed after a compound fracture of the
skull over the right Rolandic area, with opening up of the dura and
laceration of the brain causing hemiplegia. In my case just recorded
the bullet was removed from the left temporo-sphenoidal region about
1 in. behind the left ear, where it had lodged without any evidence of
penetrating the internal table of the skull.

The two cases of organic dementia were both associated with severe
cranial injury. In one the injury was of sixteen years’ standing, and
in the other the patient had metal in the right cerebral hemisphere,
with a destruction of brain-tissue causing a left-sided hemiplegia.

The cases of mental deficiency had all been below the average in
intelligence prior to enlistment, but there was evidence to show that
the injury had somewhat lowered their pre-war standard. One had
been reduced to the level of an imbecile who was quite unable to look
after himself in any way since receiving a superficial wound of the
scalp of the frontal region. He had previously earned his living as a
carter. Another, after nine months’ service, received a fracture of his
skull from a bullet. Fe was in hospital about six weeks and discharged
to his depot, but found unable to understand hardly anything that was
said to him, and on this account had to be sent to hospital again.

It will be seen, on the other hand, that all the cases described as
morally defective had injuries of a superficial nature.

I now propose to deal with the analysis of these cases more closely
under groups made in accordance with the site of the injury.

Frontal Injuries.

Of the 100 cases it will be seen that 28 were frontal injuries. Ten of
these were left-sided, 10 right-sided, and 8 over the middle line.

It will be noted that only one case of epilepsy is accounted for in the
frontal injuries. This was the case of a man who died in a condition
of status epilepticus lasting four days. He had received a gunshot
wound of the right frontal region twelve months previously, for which

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he had subsequently had a trephine operation and a frontal abscess
evacuated. Since then, and four months after the injury, “ fits ” had
developed. He subsequently had two attacks of status epilepticus,
after which on each occasion his mental condition showed definite
deterioration with marked memory defect. He came under my observa¬
tion a few days after the second “ bout ” of fits, and died a month later.
A post-mortem examination was performed, and a trephine opening
measuring in. transversely and 2 in. from above downwards was
found in the frontal bone £ in. above the right eyebrow. The margins
of the trephine opening were smooth, and the opening was occluded
by dura mater. The pia arachnoid was found adherent to brain over
the first, second and third frontal convolutions of the right hemisphere,
and the surface of the brain substance over this area was yellow in
colour. On section the grey matter of the external surface of the
right frontal lobe was practically disorganised; but on the other hand
there did not appear to be any involvement of the white matter as far
as could be seen macroscopically. No metal was present in the skull,
and the rest of the brain appeared to be in a healthy state. The weight
of the brain was 57 oz.

Whereas the number of cases of epilepsy amongst the frontal injuries
was low and limited to one case only, the number exhibiting states of
complete dissociation, such as amnesias, was found to be comparatively
high. Half of the total number of cases in which this was the pre¬
dominant symptom were found amongst the injuries of the frontal
region. In three of these cases the period of amnesia had lasted for a
month and upwards, and in the other three the amnesia was of shorter
duration but recurring at frequent intervals. Most of these cases
complained of a feeling of pressure in the head as an associated symptom.
In only one case could alcoholic intemperance be found to be an
associated factor. The following is a typical example of one of these
cases with amnesic fugues.

Patient was wounded in the forehead by a shell from a trench mortar
whilst coming out of a sap. He was rendered unconscious, and came
to himself the following morning whilst in a field ambulance. He was
only kept in hospital three or four days, and rejoined his battalion in
the trenches two months later. Three months after this he was again
wounded and evacuated to England, the wound on this occasion being
in the elbow. This eventually healed, causing no disability, and he was
given ten days’ furlough in order to proceed home to Ireland to visit his
mother. Two months later he was found by the police in civil clothes.
He stated that he was on his way to report himself to his unit when
arrested, and this appeared to be the case, for on examination medically
it was found that he had a complete amnesia as to what had happened
from the time of his arrival in Belfast till two months later when he

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1920 .]

BY RICHARD EAGER, M.D.

II 7

had “ discovered himself ” on Clapham Common. He then found
himself in civil clothes, but had no idea where he had obtained them.
In his pocket he found a ‘ pass ” giving him authority to proceed
to Ireland, and instructing him to report at his depot at the expiration
of his furlough. He remembered landing at Belfast, but everything
else seemed “blank,” and he could not remember whether he had seen
his mother or not, for which purpose he had proceeded to Ireland.
Having no money in his pocket he proceeded to walk to his depot,
and it was whilst so tramping that he was arrested. He complained of
a feeling of a painful tight band round the forehead, and that on
previous occasions, whilst in the trenches and since his head injury,
he had had feelings that certain days were “ quite blank.” He was
somewhat depressed, and seemed to have considerable anxiety as to
whether he would fall a victim to another of these attacks. On
examination of the skull a definite bony ridge could be felt on the
centre of the forehead extending to about i in. above the centre of
the left eyebrow. X-ray examination confirmed the presence of a
definite fracture which had apparently escaped detection previously.
One other point is worth notice, namely, that the only two cases
recorded under the heading of delusional states occurred amongst the
frontal injuries. One was a superficial injury and the other deep. In
the latter case the delusions led the patient to believe that he was
being looked upon as a German spy, and these ideas developed within
four months of receiving a fracture of the frontal bone by shell. The
other case developed ideas that his correspondence was being tampered
with, and that some unseen agency was working against him. This
patient had received a frontal injury twelve months previously, but the
above ideas did not develop till he was again in hospital with a wound
of his hand. It will be observed that two of the three cases of mental
deficiency had frontal injuries, whereas none of the cases in which
the moral side of the patient’s character seemed to have been chiefly
affected were associated with injury of the frontal region.

Our conception of the consequences of frontal injuries prior to the
war was based on the work of Ferrier, Horsley and others who have
contributed particulars of isolated cases. But the opinions expressed
were somewhat indefinite. Ferrier found no appreciable result by
stimulation and extirpation of the anterior part of the frontal region in
monkeys, but his experiments tended to show that on removal of this
area such animals appeared to be more restless and more easily
distracted. It also seemed that under prolonged examination before
and after the experiments there seemed to be a distinct loss of the
persistence shown by monkeys with extirpated frontal lobes to obtain
things, such as a nut, in comparison with normal monkeys. In the
celebrated crowbar accident due to the premature explosion of a charge

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I 18 HEAD INJURIES IN PSYCHOSES, [April,

of dynamite in an American mine (5), we are told that the patient
recovered and returned to his work as overseer of the mine, but that
there seemed to be a change in the man’s mental qualities comparable
to Ferrier’s observations on monkeys and a deterioration of moral
character. Oppenheim (6), in discussing the localisation of the cerebral
cortex, says : “ To all appearance the frontal lobes play a prominent part
in the higher mental functions, and excision of a tumour compressing
the frontal lobe has been followed by the disappearance of mental
symptoms.”

From the cases that have passed through my hands, however, there
seems to be no uniformity in the psychic symptoms that may follow
frontal injuries, and the tendency that there has been in the past to
consider as a special characteristic of injuries in this region the likeli¬
hood of the moral character of the individual to suffer most is not
supported.

Parietal Injuries.

These account for 38 out of the 100 cases. Amongst this group we
find 12 out of the 15 cases of epilepsy, all of which were associated
with some gross head injury, except one in which the wound was
superficial. In the majority of cases the injury of bone was so extensive
as to be almost incredible. Fig. 1 illustrates a case with a trephine
opening about 2 in. in diameter over the upper part of the right parietal
region involving part of the Rolandic area. This was the result of a
shell-wound received in February, 1917, whilst sniping in Mesopotamia.
He was ten days unconscious, and after operation was evacuated to
Bombay, where he arrived on March 21st, 1917. About four days later
he had his first fit, the wound being then practically healed. He was
returned to England and received in hospital here about the middle of
September, 1917, when he had a depression over his parietal bone corre¬
sponding to the site of the trephine opening, and also showed evidence
of a left-sided hemiplegia. As regards this he showed signs of improve¬
ment in the upper extremity, but with the exception of slight movement
in the hip the lower extremity was completely paralysed. There was
no facial or oculo-motor paralysis, and sphincter control was not
affected. His physical condition improved to the extent of enabling
him to be up and about with full power of his arm, but still a slight
paresis remained in the leg. Towards the end of October, 1917,
however, he had a succession of fits in which the convulsions were
generalised in character, and these were followed by an outburst of
maniacal excitement. This condition lasted a few days, when he
showed a certain amount of clouding of consciousness for the period
covered by his maniacal attack, but was otherwise free from any
symptoms. His chief complaint was of pain localised to the frontal

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BY RICHARD EAGER, M.D.

I 19

region, chiefly over the left eye. He said the pain was made worse by
any exertion, and he could not stand any noise. Just preceding the
fits he had hallucinations in the form of the sound of bells ringing in
his ears, and then his sight seemed to go dim. In the course of the
next three months this patient only had one fit which was not followed
by any period of excitement.

The frequency with which epilepsy followed gross head injury in the
parietal region amongst the cases which came under my notice corro¬
borates the results already published by Roeper. (7) The only case in
which there was no evidence of the skull being injured was that of a
man who suffered from concussion following a collision with another
man on a motor bicycle whilst despatch riding. No fracture could be
detected nor was there any external indication of any injury to his head.
He had, however, a small septic wound below the ramus of the lower
jaw on the left side of his neck. He walked with a very pronounced
limp on the right foot, and on examination there was an apparent
shortening of the leg on this side. This was on further examination
found to be accounted for by a tilting of the pelvis to overcome a
paresis with slight foot-drop. This patient on admission also showed
some right facial and arm paresis, and fits of a definite epileptic nature
started three months after the accident, recurring singly at intervals of
about a month. Although I think there can be little doubt that this
case had an organic basis, probably of the nature of a haemorrhage
about the surface of the left Rolandic area, I am also of opinion that a
functional element was superimposed, and that his gait was steadily
progressing towards one of those “habit gaits” which have been dealt
with very fully by Roussy. (8)

On referring to the table we find in the parietal region the only case
of mental deficiency outside those already included in the frontal
injuries. After having been repeatedly rejected as unfit for service this
man had eventually managed to enlist in October, 1915. He went to
France, and in July, 1916, was struck in the head by a bullet, receiving
a fracture of his left parietal bone when trying to get water from a shell-
hole. He complained of headache and dizziness and was found to
have a well-marked paresis of the left facial nerve and to be quite deaf
in the left ear, but apart from a pronounced mental deficiency showed
no other symptoms. Prior to enlistment this man had spent his life as
a hawker, but had never learned to read or write. It appears, however,
that his mental defect must have been somewhat exaggerated after his
head injury, for whereas he had previously been sent overseas, on
return to his depot for duty after his head injury he was at once sent
to hospital again, and it was in this way that he came under my
observation.

It is in this group of parietal injuries that we find three of the four

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cases classified as moral deficiency, in which the moral side of the
patient’s character seemed to be the most seriously affected.

One of these cases was wounded by a shell splinter just above the
right ear. He was for the moment dazed, but was able to walk to
the dressing-station. He was sent to the base, but only kept there
a few weeks and rejoined his unit again two months after being
wounded. Here he is now noted as showing marked insubordination,
and his O.C., in making a note with regard to him, says “he has
quite changed in his character since his head injury,” and he is
further described as laughing in his officers’ faces on parade and
seeming to have lost all sense of discipline. This man had eight
years’ colour service with a good character and freedom from any
crime or tendency to intemperance, but since his head injury had
taken to drink on the slightest provocation and seemed to have no
power to resist the temptation. Further inquiry from his relatives also
elicited the information that prior to his head injury he had been
a staunch teetotaller and a very steady man in every way, and his
character now seemed quite the opposite. This man had received
his promotion to the rank of corporal in France due to his steadiness
in action, and since his head injury had been reduced to the ranks.

Another case was that of a boy, set. 19, who was wounded by bullet
over the upper part of the left parietal region when sniping in a shell-
hole near Guillemont. He had been promoted corporal eight days pre¬
viously, and the good character given him by his father and other
relatives when questioned about his former morals was supported by
the schoolmaster of one of the large public schools where he had been
educated, as well as the head of an agricultural college where this boy
was learning farming when he enlisted. Whilst in hospital a few weeks
after being wounded this boy became restless and showed extreme
irritability. He demanded to go home before his wound was healed
and threatened to run away if his request was not acceded to. He
lacked self-control, and threatened to strike anyone who “ crossed ’*
him in any way. These acute symptoms to a great extent subsided,
but he subsequently showed a type of “ pseudologia phantastica ”
which it would take far too much space to enter into here. He was
a notorious liar and full of deceit in every conceivable way. No
reliance could be placed on anything he said or did, and his father,
who, against advice, took him home, had to return him again to
hospital owing to his kleptomania tendencies, stating at the same time
that his character had quite altered to what it was prior to his head
injury.

The third case was that of a Canadian, who apparently had always
been somewhat below the average in intelligence. He received a
shell-wound of the right parietal region after two years in France and

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121

was unconscious about two hours following the wound, which, however,
on examination proved to be only of the nature of a scalp wound about
2 in. long. He was subsequently returned to his unit, when he exhibited
a change in his moral character. His O.C. reported that before his
head injury he was a well-behaved soldier, but since then had been
most unreliable, had had three court-martials, and practically lived in
detention. No punishment seemed to make the slightest impression
on him, and he had taken to drink and other bad habits which were
previously quite foreign to his nature.

The only case returned as vertigo will be seen in the table to figure
amongst the parietal injuries. This was a case following a shell-wound
of the left parietal area causing an apparently superficial scalp-wound
about 2 in. long in front of the anterior vertical line of Reid. On
examination, however, there were definite signs of a right-sided paresis.
There was probably some cortical or meningeal haemorrhage in this
case therefore. He complained mostly of dizziness, which came on
suddenly, and had on one or two occasions caused him to fall but not
to lose consciousness. The ground seemed to give way under him in
these attacks. He also was found to have some deafness in the left
ear, which on examination revealed no abnormality further than some
loss of polish of the left membrana tympani. The parietal injuries also
include the only case which was returned as psychasthenia. This took
the form of a syphilophobia which developed some months after a
bullet-wound of the posterior part of the left parietal region, which
was of the superficial character.

Of the two cases of organic dementia one was after a parietal injury.
This was the case of a man who had an old depression in his right
parietal bone corresponding to the circular opening in the skull. His
history-sheet showed that he had received this injury fifteen years
previously whilst serving in China, and it was interesting to note the
appearance seen in X-ray examination, suggesting that an effort had
been made by Nature to narrow the opening by a deposit of osseous
tissue at the circumference. This man re-enlisted at the outbreak of
war in August, 1914, and went to France, but at the end of twelve
months showed signs of mental deterioration, which rapidly progressed
into a state of marked dementia with childishness and gross memory
defect.

It was in these gross lesions of the parietal region that hemiplegias,
aphasias, apraxias and such conditions were met with.

Occipital Injuries.

There were a comparatively small number of w’ounds of the occipital
region, and only two in all were of a serious nature. The total number

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of cases in this group was io, and of these 3 were right-sided, 2
left-sided, and the remaining 5 more or less in the middle line.
Amongst those with superficial injuries was one of the three cases of
epilepsy occurring in injuries of this kind. He was, however, of the
constitutional type of epilepsy, and had had a fit following an attack of
pneumonia when eight years old. Active service had evidently brought
out this latent tendency. After burial by shell also, prior to his head
injury, he had had another fit on account of which he had been removed
from the front line. During the Somme advance, however, he was
returned to his unit and was wounded in the hand, and it was whilst
having his hand attended to at a “ first-aid post ” that the roof of the
dug-out fell in and he was struck on the back of the head by a fall of
timber. He was unconscious some hours and has since had fits at
intervals of about once a month.

The two cases whose injuries were of a more serious character were
both right-sided injuries and were both mentally melancholics. One
had a definite depression to be felt as the result of a blow on the head
from a girder of a bridge under which he was sheltering from shell-fire
after being wounded in the leg. He was returned to duty three months
later, but still complained of constant headaches and felt quite unable
to do his duty. He was subsequently admitted to hospital in a state
of acute melancholia, having made an attempt to end his misery by
strangulation with his puttees. X-ray examination revealed an evident
widening of the lambdoid suture, from which there was also seen a
small fissured fracture running forward which had evidently not been
previously recognised.

The other case was one in which there was extensive loss of bony
protection at the back of the skull as the result of a shrapnel wound
received in November, 1914. He had since suffered from buzzing
noises in the head which made his life a misery. This man during
examination admitted that he had contemplated suicide on this account,
but no active steps towards this end had been made at the time he
came under my observation.

Temporal Injuries.

This group accounts for 13 cases, all of which were superficial,
except 3 which were cases of fracture, and in one of these metal
had penetrated the skull. They were equally divided between both
sides of the head, except for the last 3 cases, 2 of which were left¬
sided and one right.

Of the cases with superficial injury, which were of an apparently quite
insignificant character, the universal complaint of severe cephalalgia
was a conspicuous feature. In some cases it was so severe as to make
the patient giddy and cause him to sit down.

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JOURNAL OF MENTAL SCIENCE, APRIL, 1920.

Fig. 1.

Fig. 2.

^ -To illustrate paper by Dr. Richard Eagkk.

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1920 .]

Of the more serious injuries one was a case of melancholia following
a penetrating wound of the left temple by a shell splinter. Fig. 2 is the
print from the X-ray plate of this case, which shows very well the
foreign body in the roof of the sphenoidal sinus. Here, again, pain
was the prominent symptom which had made the patient miserable.
It is also of importance to note that the patient had been informed in a
previous hospital that he had a piece of metal in his skull. This had
not helped the patient, for it was discovered by examination that this
patient had convinced himself that there must be a large piece of metal
pressing on the brain and that he was therefore doomed to lifelong
misery. With his troubles thus increased he considered himself better
dead, and he ultimately made active steps to hasten this end by
strangulation. When admitted under my observation he was in this
frame of mind, and it is interesting to note that by therapeutic conver¬
sations and re-education of his erroneous ideas a marked improvement
in his condition resulted, and in six months he expressed himself as
quite free from any feeling of depression and stated that the pain in his
head was considerably relieved. Twelve months after this man’s dis¬
charge from hospital he replied to my communication asking after his
condition and informed me that he was keeping well.

One of the other two cases had periods of amnesia following a
depressed fracture of the left temple. One amnesic period covered two
months, and was followed by other periods in which the patient seemed
confused and wandered about aimlessly. The death of a brother was
found to be an additional source of anxiety in this case. The remaining
case was one of maniacal excitement and alcoholic intemperance
following a fracture of the right temporal bone two years previously
This was a case clearly illustrating an instance of the refuge sought for
in alcohol as an attempt to gain relief from persistent pain in the head,
and the disastrous results which follow in cases with a previous head
injury.

Wounds ok the Mastoid Process.

There were 6 such injuries in this series of head injuries. Three
were superficial and 3 deep, and they were equally divided between
both sides of the skull.

The case I will quote is that of an acute hallucinatory state with
excitement in a man who had received a perforating bullet-wound.
The bullet had entered below the left orbit and found its exit at the
right mastoid process. The auditory nerve was completely severed,
and the antrum and middle ear thrown into one. A chronic otorrhcea
persisted up till eight months after the injury, when an acute condition
lit up again. He developed a temperature of io 3 - 8° F., and was for

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four weeks in a state of acute maniacal excitement with very vivid
hallucinations of sight. He convalesced satisfactorily in a further period
of two months.

The case of dementia praecox is the one already described.

Wounds of the Face.

The 5 remaining cases are included under this group. One was a
comparatively slight injury from a shell splinter below the right eye. He
was, however, at the same time blown up by the shell and subjected to
severe concussion. After admission to hospital he complained of very
severe pain in the head and behind the eyes. On examination he was
found to have a small nodule of metal opposite the infraorbital foramen,
and it was thought that there was a fracture of the infraorbital margin
of the orbit. The pain persisted, and two months later he developed
maniacal symptoms. These rapidly subsided, however, but the pain
remained. There was no optic neuritis or other signs of intracranial
pressure to account for this acute attack.

Another case was one in which hysterical deaf-mutism followed a
suggested side-to-side perforation over the region of the temporo-
maxillary articulation, and this man had such a miraculous escape that
I think for that reason alone there would be sufficient excuse for
recording his case. He was a sergeant in the Welsh Guards, and his
wounds were caused by shrapnel. One bullet appears to have passed
through the head from left to right just in front of the ears and above
the articulation of the inferior maxilla on either side. It lodged in the
wound of exit, from which it was removed. In transit it smashed the
plate of false teeth the patient was wearing, but did not apparently
damage the palate. A second bullet struck him over the centre of the
left clavicle killing his chum next to him, and a third bullet struck a
bullet-proof mirror which the patient was carrying in his left breast¬
pocket. It was in this way prevented from entering his chest. He
managed to crawl about fifty yards to the dressing-station and then lost
consciousness. About twenty-four hours later he came to himself again
and found he was in hospital at the base. He was from there evacuated
to England, and it was here about three months later that he lost his
speech and hearing, which was restored by appropriate therapeutic
methods within a few days of his admission to the psychiatric section.
This is one of only two cases with hysterical deaf-mutism met with
amongst these ioo cases, the other being amongst the parietal
injuries.

Another case of injury to the face was that of a man who, whilst in a
charge on the German lines, was wounded by a hand-grenade thrown
from a German trench. He was terribly mutilated and disfigured. In

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Fig. 3.

To illustrate paper by Dr. Richard Eager.

Ad lard Son & West Newman, Ltd.

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1920.]

addition to losing his eye he had a fracture of the upper jaw, the front
part of the alveolar margin of which seems to have been blown away.
The nasal bones were flattened out and apparently lost, and his
face was covered with scars. The lower lid on the right side was
everted and bound down to scar-tissue on his right cheek. Ten days
after his injury he became very depressed, and a few days later his
condition changed into one of acute maniacal excitement. This phase
lasted about a month, when he again became dull, depressed and
apathetic, and refused all nourishment except liquids. This condition
lasted about three months, when he steadily made improvement and
regained a normal mental state. This was maintained and enabled
him to be transferred to another hospital for a plastic operation.

The fourth case was wounded by a shell splinter on the left side of
his face whilst asleep. He had a granulating scar extending from the
external angle of the left orbital process of the frontal downwards on to
his cheek and another scar on the bridge of his nose. X-ray examination
showed a fracture of the outer part of the floor of the left orbit. This
injury was followed by a period of amnesia lasting fifteen days, during
which he was somewhat dull and stupid in appearance, but otherwise
showed nothing particularly the matter with him.

The only remaining case to be described is that shown in Fig. 3.

This was a case of dementia following a shell-wound, the fragment
from which had penetrated the left orbit, destroying the left eye, and
lodged itself finally in the centrum ovale of the right hemisphere. It
had evidently severed the internal capsule in transit, for the patient had
a complete hemiplegia affecting the left arm and leg and left side of
the face. This man could give little information about himself, and
his memory was very seriously affected. He was extremely irritable,
continually asking for food and attention, and seemed quite unaware
of the fact that only a few minutes previously he had received both.
His left arm was in a state of contracture, but the leg was flaccid with
anaesthesia; extensor plantar reflex was present as well as ankle-clonus
and increased tendon-jerks. His face was flattened on the left side,
and the mouth drawn slightly to the right. He constantly cried out,
complaining of pain in the right side of the head, which he referred
mostly to the frontal region, and he was altogether in a most pitiable
condition.

Summary and Conclusions.

In summarising my observations on this series of head injuries I will
call attention to the following points:

Out of the 100 cases 49 had evidence of serious cranial injury, 14
had trephine openings in the skull, and 12 had metal still remaining in
the cranial cavity.

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Incidence. —From figures published up to date (9), the proportion of
total head injuries to total disabled works out at 4 per cent., and from
the same figures 75 per cent, is quoted as the proportion of insane.
As, however, in my experience the proportion of head injuries which
occurs amongst the insane admissions in a large hospital for receiving
mental patients is only 2 per cent., it may be assumed that the pro¬
portion of head-injury cases that subsequently become insane is some¬
where about '375 per cent., which is not far removed from the ratio of
insane to the population in ordinary civil life. The small number of
head injuries, therefore, in which mental symptoms have developed is,
I think, a point worthy of notice, and must lead us to alter our pre-war
conceptions with regard to this subject.

Epilepsy. —Here again I must draw attention to the relatively small
number of cases met with. Only 15 per cent, were epileptics, and all
these occurred amongst cases with serious cranial injury except 4. Of
the latter one was known to have had fits as a child.

The cases of epilepsy therefore vastly predominate in cases where
there has been some gross cranial injury, and especially so where the
injury was of the nature of a penetrating wound, for all except one of
the 11 cases had wounds of this nature. In 4 instances metal still
remained in the skull, and one case had an abscess of the frontal lobe.
Eight cases had been trephined. The period of interval between the
head injury and the first fit varied from a few hours to years, but in the
vast majority of cases was about five months after the injury. In only
one case did the fits seem to start directly after the injury, recurring at
intervals of every ten days. The intervals between successive fits were
irregular. In some cases they were daily, in others weekly or monthly.
There were two cases of status epilepticus. One occurred twelve months
after the injury; the other case had three bouts of this condition at
intervals of five, eight, and ten months after his head injury, and he died
in the last attack after a succession of eighty-six fits extending over the
last four days of his life. The almost universal occurrence of these
epileptic cases after injuries of the parietal region of the skull has
been already pointed out. Nearly all cases with large osseous defects
were epileptics, and here I wish to draw attention to the warning given
to operating surgeons by Col. L. B. Rawling (10), that the smaller the
osseous defect left after operation the less dangerous from the point
of view of epilepsy.

Amnesia. —Of the 12 cases showing this condition as the pre¬
dominant symptom 6 were frontal injuries, and 4 of these superficial.
The other 6 cases were fairly evenly distributed over the other areas.
No relation seems to exist between the amnesia and the severity of the
injury. Half of the cases had superficial injuries; on the other hand
there were instances amongst these cases of fracture of the parietal

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temporal and malar bones, and one case had a piece of metal in the
great longitudinal fissure. There can be little doubt that to the medical
man without any special knowledge or training in such conditions these
cases of amnesia present considerable difficulty. Especially when these
attacks occur with “ fugues ” in men under active service conditions, it
is not always a simple matter to distinguish them from an avoidance
of duty which is purposive on the patient’s part. Where, however, in
addition, the man has had a definite head injury, I think a little more
benefit of the doubt might at all events be given in his favour. Amongst
my series of cases were instances in which N.C.Os. had been reduced
to the ranks for “absence without leave” where it had not been
recognised till long afterwards that these periods of absence were
really amnesic fugues following on a head injury. Any effort to obtain
justice for these men at this late stage of the proceedings was doomed
to failure.

Acute hallucinatory states. —There were 8 cases of this nature, and
in 4 of these there was a definite history of sepsis. Such a case has
been described amongst the injuries of the mastoid region.

Mental deficiency. —It has been already stated that the 3 cases
returned as such were cases in which the head injury had not apparently
produced any fresh symptoms, but seemed to have increased the
severity of those already existing, and so reduced a case of this kind to
a lower level of intelligence. In addition to these cases there were,
however, 12 other cases investigation of which elicited the fact that
mental deficiency was an underlying condition, existed prior to enlist¬
ment, and had been superimposed by other symptoms following the
head injury. Apart from cases of head injury, however, this was quite
a common feature in the war psychoses generally, as has been pointed
out by Major Stanford Read (n) whilst medical officer in charge of
the Mental Clearing Hospital at Netley. In the 12 cases mentioned
above the superimposed symptoms were of wide variety. Two cases
developed epilepsy, and in both cases the injury was a parietal one,
1 became melancholic following a fracture of the frontal, 4 exhibited
states of mental confusion and hallucinosis, 2 of which followed fractures
and 2 superficial injuries. Two were of the amnesic variety following
superficial injuries of the temporal region, 2 were of the mentally
unstable type of individual, and 1 was a case in which the moral side
seemed to have been the one chiefly affected.

Heredity and previous attacks. —Whereas there were 4 cases in which
there was a history of previous confinement in an asylum, there were, on
the other hand, 3 cases with over eleven years’ continuous service in the
army with good character. Of the former also it should be mentioned
that 1 case had a kick in the forehead from a horse, causing a fracture
of the frontal bone, prior to his admission to the asylum. An inquiry

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into the family history of the remaining cases brought forth no evidence
of conspicuous neurotic tendency, and therefore it seems difficult to
support any argument that hereditary predisposition is a factor of any
great importance in these cases.

Alcoholic intemperance .—Out of 14 cases in which it seemed that
alcohol was an associated factor, further investigation showed that in
8 of these cases the intemperance had developed since the head injury. I
am of the opinion that the tolerance to alcohol is considerably diminished
by head injury, and it is probable that the injury brings about a loss of
power of inhibition in this respect.

Other symptoms .—The commonest subjective symptoms were a feeling
of restlessness and irritability, a lack of confidence, and an inability on
the part of the patient to concentrate his attention on anything. One
case expressed himself as follows: “ Before my head injury I used to
fear neither God, man, or the Devil, but now I have a feeling that
something stops me doing things I used to do.” This feeling seemed
to be practically universally present in greater or less degree, but not
more conspicuously so in injury of any one area more than another.

Pain was also a fairly constant symptom varying in intensity, though
generally severe in character, and usually, but not universally, referred
to the site of injury. Noise seems to make the pain worse, and it is
invariably aggravated by stooping. The common occurrence of head¬
ache, which was so often of a persistent nature, no doubt accounts for
the high percentage (22 per cent.) of cases of the melancholic type.
In many such cases one not infrequently found that the pain had been
so severe that the patient had taken on duties involving exceptional
risks with the sole object that by so doing he would find a final release
to his sufferings. The refuge sought for in alcohol as a relief to these
symptoms has also been referred to, and needs no further emphasis
here.^) Pain was comparatively rarely complained of in cases where
there had been a trephine operation, except as a premonitory symptom
to “ fits.” The constant unbearable pain complained of in the cases
with apparently superficial injuries was, however, not met with in those
trephined. In the case already described amongst the occipital injuries
in which there was a large deficiency of bony protection at the back
of the skull pain was not complained of. Here it seems that the
hallucinations were responsible for the melancholic state. It seems,
therefore, clear that pain associated with apparently superficial injuries
is to be regarded as of some importance, and the number of cases who
had been returned to duty still complaining of pain shows that this is
not sufficiently often regarded as such in these cases. A case in point
received a superficial wound of the skull on October 21st, 1916. He
managed to land in hospital in England, but was eventually discharged
to his depot still complaining of pain. He could gain no relief for

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this, and a month later he volunteered to return to France. His wish
was acceded to, and four months later he was sent back to England
again as unfit to perform his duties. He was in hospital two months
when he was again discharged as fit for duty, but still complaining of
the pain. Two months later he was admitted to hospital again with a
cut-throat wound. Another patient with a similar history and the same
intention conceived the somewhat unique idea of achieving this end by
completely severing his right tendo-Achillis. Other cases could be
mentioned, but I think these are sufficient to emphasise the importance
of pain in the head as a symptom in cases of head injury, even though
this seems to be of a superficial character.

X-ray examination .—No relationship can be found to constantly
exist between the apparent injury or superficial scar and the actual
damage to the skull, and therefore I feel that X-ray examinations should
be more universally made in the cases in which the head injury appears
to be of a superficial nature. Some do not seem to realise the importance
of this, whilst others definitely discourage the use of X-ray examination
in cases of the psychoneurotic type on the ground that the information
so obtained is sometimes conveyed to the patient, on whom it has a
detrimental influence. (12) Such a case, it must be admitted, was met
with amongst this series of head injuries and is shown in Fig. 2.
But with the provisio that information obtained by this method of
examination will not be unnecessarily handed on to the patient I
would urge its more general application, for there were many cases
where gross injury to the skull was found in which X-ray examination
had been neglected prior to admission to the psychiatric section. One
man had been blown up by shell and was unconscious when found.
His mouth was then drawn slightly to the left side, but this soon
returned to normal, and his chief complaint was of thumping pains in
the head. Three months later he developed epileptic fits. There was
no evidence of head injury to inspection or palpation in this case
when he came under my observation, and had it not been for the
information gained by X-ray examination an extensive fracture would
have escaped detection, and little credit would have been given to the
patient for his head injury.

Conclusions .—In considering these cases of head injury in detail one
is struck by the impossibility of grouping them in any way which
would show any relationship between the mental symptoms presented
and the site of the cranial injury. Hollander, in his book published in
1910(13), described a whole host of cases of head injury, and argues
that injury of the frontal region produces loss of self-control going on
to dementia, injuries of the parietal region produce symptoms of melan¬
cholia, injury of the temporal region mania, and that emotionalism and
loss of inhibitory power over the muscles that express the affective state

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follow injuries of the occiput. But I am unable to support his findings.
On the other hand, it seems clear that epilepsy is most commonly met
with where there has been gross damage to the walls of the skull, and
especially so when in the parietal region. Pain is an important symptom
almost universally present even in quite trivial injuries, especially so
when such occur in the temporal region, and I wish here to lay emphasis
on the necessity for more sympathetic consideration to be given to it
than appears to be done by many medical officers dealing with such
cases in surgical wards. Further, it is deplorable to observe how the
attitude of the average physician or surgeon completely changes towards
his patient who presents any symptoms which cannot readily be accounted
for by physical causes. He at once loses all interest in the patient,
which I venture to suggest is instantly recognised by the patient and
only adds to the distress of the latter, with often fatal consequences. A
definite irritability of temper and loss of power of concentration was
an almost universal accompaniment in these cases of head injury,
without any indication that it was more pronounced or more commonly
present in injuries of any one special region of the head. It seems, as
MacCurdy(i4) says, that in many cases in which there have been
gradually accumulating difficulties not sufficient to incapacitate the
patient there is a sudden increase of symptoms following even a mild
concussion, and that in the low state of mental tension consequent on
cerebral injury higher functions are in abeyance, and the unconscious
and instinctive tendencies readily gain the upper hand. A great
number of cases on analysis showed the existence of mental conflict
of repressed complexes, as is so ably desciibed by Hart (15), and treat¬
ment on psycho-therapeutic lines in most cases speedily relieved the
mental symptoms, and in not a few instances the headaches also seemed
to be diminished in severity. It has been pointed out by Farrar(16),
Turner(i7) and Hart(i8), and is now generally accepted, that the
“ traumatic neuroses ’’ in which every nervous phenomenon including
dissociated states of consciousness are exhibited are “ functional dis¬
orders” brought about by the psychic and not the physical shock.
So it seems that in these cases of “traumatic psychoses” with bead
injury the mental symptoms were referable to psychic rather than
physical causes.

I am much indebted to Capt. W. H. Hooton, Radiologist to the
Lord Derby War Hospital, for much time and trouble spent in furnishing
me with X-ray reports and photographs.

References.

(1) The Journal of the Royal Army Medical Corps, September, 1916
and 1918.

(2) The British Journal of Surgery, vol. ii, July, 1915, to April, 1916.

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1 3 1

(3) Purves Stewart.— The Diagnosis of Nervous Disorders.

(4) Capt. H. J. Norman.— The Review of Neurology and Psychiatry,
August-September, 1917.

(5) Halliburton’s Handbook of Physiology : “ Functions of the
Cerebrum.”

(6) Oppenheim’s Text-Book on Nervous Diseases, vol. ii.

(7) The Daily Review of the Foreign Press, April ist, 1918.

(8) Roussey.— The Psycho-neuroses of the War.

(9) Parliamentary Report, May 28th, 1918.

(10) Meeting of the Medical Society, London, November 15th, 1915.

(11) “A Survey of War Neuro-psychiatry," The American Journal
of Mental Hygiene.

(12) Journ. Ment. Sci., October, 1918, p. 404.

(13) Bernard Hollander.— The Mental Symptoms of Brain Disease.

(14) J. T. MacCurdy.— War Neuroses , Cambridge University Press.

(15) Bernard Hart.— The Psychology of Insanity.

(16) C. B. Farrar.— American Journal of Insanity, July, 1917.

(17) “The Bradshaw Lecture on Neuroses and Psychoses of War,
Lancet, November 9th, 1918.

(18) Bernard Hart.—“The Modern Treatment of Mental and
Nervous Disorders," Manchester University Lectures, No. xxi.

(') Paper read at the Autumn Meeting of the South-Western Division of the
Medico-Psychological Association, University College, Bristol, October 24th, 1919.
(*) Since writing these views, the author is glad to find that Stanford Read in
Military Psychiatry in Peace and War, published by Lewis & Co., expresses
somewhat similar views. This book is highly commended.

Some Points of Interest in connection with the Psychoneuroses of
War.('}) By George Rutherford Jeffrey, M.D., F.R.C.P.E.,
F.R.S.E., Medical Superintendent, Bootham Park, York.

Upon the outbreak of the recent war, most of us, after experiencing
a transitory phase of almost breathless suspense, passed, I think, into a
state of apprehensive ignorance. Inwardly we had a feeling of un¬
certainty, but had indeed little idea of what the war would unfold ; still
less did we realise that we would have to face and counteract such
countless schemes and devices which had been prepared for our
destruction. As time went on we gradually found that we were almost
instinctively prepared, or, at least, in a position to react and protect
ourselves. Such a state of affairs was not an experience confined to
any one branch of the services: the medical department experienced
the same. Very soon this department recognised that difficult times
were ahead, and that they would have to treat, not only the ordinary
battle casualties, but many other conditions apart from ordinary
surgical and medical cases. So the various specialties of medicine
were affected, and none more so than that which dealt with affections
LXVI.

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implicating the nervous system. Soon the authorities had to give
special attention, not only to the care and treatment of the many cases
of undeniable mental disease, but also to a greater problem, namely,
the large group of conditions comprising the psychoneuroses. There
began to appear endless literature on the subject, which is still forth¬
coming. I mention this fact principally in order that it may be realised
how difficult it is even to attempt a brief risume of this important
branch of medicine, comprising the psychoses, neuroses and psycho¬
neuroses. In addition I do not feel justified in expressing definite
opinions, generally speaking, largely on account of the limitations of my
military experience. I had not the opportunity of seeing such con¬
ditions in the front lines, nor at the large base hospitals abroad, for,
during nearly the whole of my time in the army I was stationed at a
military hospital in this country. In this hospital, however, I had the
opportunity of seeing the more advanced cases of shell-shock, neuras¬
thenia and allied states. I shall therefore confine my remarks chiefly
to these conditions.

I say ‘'allied states,” for in considering the question of shell-shock we
cannot eliminate neurasthenia, and even psychasthenia and hysteria.
Instead of using the term “shell-shock,” I would prefer to call it “nervous
shock.” It was perhaps unfortunate that such a term as shell-shock was
generally adopted. Although its precise meaning is vague, the term is
used to include a vast number of cases presenting obscure symptoms,
and is indeed a useful basket into which can be thrown the vast number
of cases which present mental symptoms without any apparent wound
or injury. In this respect the term answered admirably; not only so,
but it had about it in the eyes of the public a plausible ring with an air
of scientific accuracy. To the sufferer himself it appealed, and it is, I
think, in this respect that the term is open to criticism. I have met
with many men who, when told that they were neurasthenic, became
bitterly resentful, and asserted that neurasthenia was the very last thing
they were suffering from, and that their condition was one of shell-shock.
To a certain type of neurasthenic the term “ shell-shock ” appealed. It
savoured of the noise and din of battle, screeching shells and great
explosions, causing, not a giving way to pent-up emotion, but a collapse
of the nervous system from actual wound. Still, we must remember that
never before in history has the human frame been exposed to such ordeals
and strains, and if in civil life shock is capable of producing a nervous
breakdown, all the more would it do so under the truly appalling trials
our men had to face. I think I might at once refer to the belief held
by many people, medical men as well as laymen, that this condition—
shock or neurasthenia—was but another name for what is vulgarly
known as “ funk.” Although in some cases we undoubtedly had to
raise the question of “ funk ” or malingering, I would point out in con-

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tradiction to this belief (1) that often the worst cases occurred in those
whose pre-war as well as actual war history could stand the most careful
scrutiny, and establish beyond the slightest doubt that those in question
had been normally men of steady and fearless character, (a) That in
a very large number of these cases we met with men who, although
undoubtedly neurasthenic and far from fit for duty, pleaded to be sent
back to the fighting line. (3) That precisely the same symptoms
appeared in the seasoned soldier as well as in the soldier with little battle
experience. (4) I have known cases to be returned more than once to
duty, in entire concurrence with the wishes of the individual, only to
break down again.

Regarding the setiological factors in the causation of this condition,
in previous campaigns the occurrence of mental disorders was by no
means rare, and the study of mental diseases was no new branch of
medicine; and yet, at the outbreak of the great war, the attitude of a
large section of the army medical department was similar to that of the
general public, who thought, and perhaps naturally, that those who were
afflicted with mental disease were but useless burdens, little deserving of
sympathy. These unfortunate invalids, in many cases the pick of our man¬
hood, who, after the dreadful trials, privations and suffering of the first few
months of the war had broken down, mentally and nervously, received,
I fear, but little sympathy. Such a state of affairs was bound to exist at
first, and amidst the bustle and burdens of the task that lay before the
authorities in making provision for the wounded it was only natural
that such conditions received only moderate attention.

As time went on, however, it became apparent that nervous and
mental diseases were going to claim a considerable number of cases,
and, this being so, provision had to be made not only for recognising
such states, but for treating them skilfully.

In support of these remarks, I recollect in the early days of the war
having seen discharged soldiers who, having broken down on service,
were finally committed to an asylum with a definite mental diagnosis.
I can recall the case of a young man who came under my care as
a case of dementia prsecox, an incurable and, at times, supposed to
be a dangerous lunatic, but his was a case of adolescent neurasthenia
—at that time perhaps a somewhat rare condition ; under proper treat¬
ment he eventually got quite well. Time showed that these were the
kind of cases which were going to be very numerous, and would form
an important group of cases requiring competent and skilled treatment.

Did the war produce any new or definite psychosis is a question
which is constantly being asked, and concerning which opinions greatly
differ.

Some assert that, although the war undoubtedly produced many cases
of mental disease, it provided nothing new. With this opinion others

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are inclined to disagree, and although they admit that perhaps there
was produced no new actual mental disease, there occurred many mental
types the origin and development of which were different from those of
peace time, and especially did we meet with a great number of so-called
borderland cases. Let me sketch what happened. The country, after
a period of suspense, was plunged into war : there was a sudden depar¬
ture from the ordinary existence, acute suspense and excitement
prevailed, and then there followed a chain of circumstances hitherto
quite foreign to most, and of such a kind as was bound to exert an
influence on the nervous system of even the strongest man. A wave of
uncertainty swept over the nation ; the leap into the dark unknown, the
noise and the bustle, the breaking up of homes, the feeling of possible
separation and death, were but a few circumstances which were bound
to exert some influence on the emotions and feelings of the strongest.
Under these preliminary adverse circumstances many broke down—
those who were mentally weak or unevenly balanced, and those of
emotional temperament. But it did not end there; our men were to
face more terrible circumstances and ordeals which undoubtedly pro¬
duced and accentuated feeling of pent-up emotion ; then came the actual
physical fatigue of marching, and the many hardships, alarms and nerve-
racking sights. These were common to all combatants, and un¬
doubtedly here again many broke down, and others who did not
actually break down became mentally weakened—they became, in
other words, suitable persons for future collapse, if not indeed potential
neurasthenics. At first it would appear as if almost all should break
down, but this was far from being so; nervous systems adapted them¬
selves in the most extraordinary way; not only so, but the inherent
stamina of the race showed itself. Thus there were in the first instance
the so-called weaklings who broke down almost at once, even during
training. Then came the second group: those usually with a poor
heredity, who had been weakened mentally by their initial experiences,
and broke down whenever they approached the battle zone. I can recall
many such cases. One case was that of an officer, never very
robust mentally, who told me that everything in connection with his
military training had worried him. On his way to the front the train in
which he travelled was bombed : he almost at once broke down, had a
so-called hysterical fit, was evacuated to the base, and admitted to
hospital in England suffering from neurasthenia. The third group
comprised those soldiers, in many cases regulars and the pick of the
army, who had experienced considerable active service, but who
eventually broke down and became nervous wrecks. I can illustrate this
group by the case of a young officer—a regular—who went with the first
draft of men to France, and saw a great deal of service for three years
before he broke down. He was strong and muscular, and a great

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athlete. He was present at the Mons retreat and marched for almost
■seventeen hours at the head of his company, carrying, not only his own
kit, but that of another. On halting for the night he took sentry duty
himself as he considered he was the fittest man in the company. In
the morning he led a counter-attack, and was but little the worse for it.
He fought on for nearly three years, full of pluck, enthusiasm and
endurance. One day he was making observations from the inside of a
tall chimney with his sergeant. A shell struck the chimney, making a
large hole and carrying away the climbing supports. His sergeant fell
to the ground and was killed. He had to descend, and yet the supports
were gone. Without thinking he released his grip, and trusted that he
would catch on to a support further down the chimney. This he
accomplished, perhaps owing to the fact that he was a great gymnast.
Immediately after reaching the ground the chimney fell, and he was
buried in some of the dibris. When rescued he was dazed and speech¬
less, and finally was admitted to hospital suffering from a severe attack
of neurasthenia. Such a case illustrates most forcibly that even the
strongest may in time collapse, and the wonder is that more did not
break down under such constant and terrible trials.

I will now briefly detail the aetiological points which appear to be
common to psychoneuroses.

Predisposing Causes.

(1) A neuropathic constitution is a potent factor, and may be
hereditary or acquired; I prefer, however, to call it “ the emotional
temperament,” a term which I first used in a paper on “The Cause
of Neuropathic States.”( 4 ) Those who inherited this diathesis had not
much chance, and furnished most of the cases who broke down almost
at once. Then the condition may be acquired. I have already shown
that even the strongest man may become so much weakened that he
readily, under adverse circumstances, breaks down. The neuropathic
constitution does not remain latent, but shows itself under circum¬
stances when the emotional reactions are brought into play, and may
reveal itself by an exaggerated expression of the mental and physical
reactions of the emotions.

(2) In fatigue, mental or physical, we have another factor that is of
paramount importance. By its depressant action it involves undoubt¬
edly a great expenditure of energy and produces a general weakening
■of mental tone.

(3) Effects produced by temporary shortage of food and the intoxi¬
cations.

(4) An aetiological factor also of importance, I think, in producing a
lowered, or, at least, changed mental state, is that to be found in the

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mental effect produced by distaste or disappointment in the person
suddenly passing from an important civil position to the position of an
ordinary soldier.

Exciting Causes.

(1) In direct concussion, no matter whether the individual has been
thrown to the grouud, against the wall of a dug-out, or actually struck
on the skull by any object, there is a shaking of the nervous system.
Although this may cause a psychopathic disorder, it more readily
produces an organic lesion. Indirect concussion, on the other hand,
produces almost exclusively neuropathic symptoms.

(2) Along with concussion we must consider local trauma which causes
motor and sensory changes in some part of the body. It produces first
of all an emotional state, and then, under cover of this, the idea of some
disorder is suggested, e. g., a severe shock to a limb may produce a
temporary paresis. In the normal individual this rapidly passes off,
but in the neuropath the idea of immobility becomes fixed by auto¬
suggestion.

(3) There is the share taken by emotion and suggestion in
psychoneuropathic conditions. Regarding this many questions require
an answer, e.g., To what extent is emotion responsible for the establish¬
ment of the symptoms in the psychoneuroses ? How far does emotion
extend? What is emotionalism? What are its physical and mental
reactions, etc ? Dejerine and Gauckler in their book on the psycho¬
neuroses say that emotion may be of external or internal origin. First
of all as regards emotional strain of external origin, a person may
receive some great shock—physical or mental—without any warning.
The shock may come in the form of sudden and great joy. In these,
the common factor is that the person passes from one situation into
another for which he is quite unprepared. Between great shocks and
slight emotional stimuli there are many grades.

Emotional stimuli may be of internal origin, e.g., the memory of some
previous shock, the feelings of impending grief or catastrophe. Gene¬
rally speaking emotion is a reaction of the personality, and, as an
immediate result, may completely overthrow the equilibrium of the
subject. As a rule the psychic disturbance is passing, followed by a
return to normal mentality. But this may not be so. The primary
effects of the emotional stimuli may remain until the appearance of
the later phenomena, constituting by the symptoms they produce the
majority of the functional troubles.

But the person who experiences one emotional shock does not become
neurasthenic unless he has been unable to free himself from the
memory of the emotion, which continues to return again and again.

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He cannot adapt himself; his mental energy begins to fail; the will
becomes powerless and he is over-ruled by preoccupation. In other
words the neurasthenic state follows his inability to adapt himself to
continued emotional stimuli.

The two chief exciting causes of a neuropathic disorder are the
revival of an emotion, and secondly auto suggestion created by emotion.
It is known, for example, as Roussy and Thermitte point out in their
book on the psycho-neurosis of war, that shock to a limb caused by
a projectile of high velocity may immediaetly produce a transient but
complete motor or sensory paralysis, but which in the normal individual
rapidly disappears. It is quite another matter in the neuropathic, in
whom this impotence becomes fixed and made stable by the action of
auto-suggestion.

The Symptoms.

I will now briefly indicate the symptoms of the condition, and for
convenience shall divide them into early and late. The early symptoms
hardly concern us except inasmuch as there is a tendency for them to
continue—perhaps in a more chronic or more intensified form—in the
later stage of the illness. A common history is as follows: Explosion
of shell; the patient is buried completely or partially, and rendered
unconscious. On regaining consciousness some of the following sym¬
ptoms may be noticed: intense headache, nervousness, tremors,
epileptiform attacks, choreiform movements, motor disorders, mono¬
plegia, hemiplegia, paraplegia, disorders of gait, disorders of hearing
and of speech, contractures, and, in addition, pronounced general
symptoms of early neurasthenia, as, e.g., insomnia, loss of initiative and
will-power, lack of power of concentration, altered heart action, etc.
Later, there may occur many of the symptoms of the early stages,
perhaps in a more intensified form, and, in addition—and this is a
point of importance—we have a prominence of psychical disorders.
They are the psychoneurotic sequelae of the most persistent symptoms
which remain and which we are called upon to treat.

The most important are :

(1) Headache.

(2) Loss of memory and lack of power of concentration.

(3) Disordered action of the heart.

(4) General nervousness.

(5) Disorders of special sensation.

(6) Insomnia.

(7) Persistent and terrifying dreams.

(8) Exaggerated tendon reflexes, etc.

Two cases are related which bring out vividly many important points
in connection with symptoms.

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The first is that of an officer who had seen considerable service.
Daring a very heavy bombardment a shell struck the roof of the
dug-out where he was with several other officers. The other occupants
were killed, and he himself was partially buried, and was firmly fixed to
the ground by a beam of wood across his shoulder. Eventually he lost
consciousness, and remembered nothing until he awoke in a casualty
clearing station, and from which he was sent to the base. He was
then intensely nervous, suffered from headaches and loss of memory,
insomnia, battle dreams and tremors, and his left arm was firmly
contracted with the shoulder raised. There was general bruising of the
shoulder and arm, but nothing more. He was evacuated to England.
After a time he improved generally: practically all the symptoms of
neurasthenia had disappeared, but there remained the contracture. I
administered chloroform and made certain that there was no compli¬
cation from fracture, although there were naturally some adhesions at
the elbow, and which I broke down. Gradually as he came out of the
anaesthetic his arm began to contract, and when completely conscious
the contracture was as marked as before. In the course of my talks
with him I convinced him that it was only a functional condition, and
that he would get quite well. Moreover I told him that I would give
him some massage, but that on a definite day—three weeks was the
time that I mentioned—his arm would be quite well. At first there was
no change in the contracture under treatment, until the three weeks had
almost elapsed ; then suddenly it improved—he got again complete use
of his arm, gained strength in every way, and, at his own request, was
returned to duty.

The second case shows very extraordinary symptoms, both mental
and physical. This was a case which I studied very carefully, and
might be described as one of traumatic neurasthenia. Along with my
notes of the case it is fully quoted in Lt.-Col. Marr’s book on the
Psychoses of War , and briefly the facts are as follows : The patient was
an officer in the Royal Air Force, and during a hostile raid over London
was caught in the fire of his own barrage and crashed to the ground—a
distance of 10,000 feet. He was unconscious for three weeks, at the
end of which time he was given leave. He was recalled and sent to a
bombing school, but his memory for the next ten weeks was a com¬
plete blank. After_ some trouble with the military authorities he was
“ boarded ” and given leave, towards the end of which he got married,
but, not only did he not remember the marriage ceremony, the place or
the church, but he did not marry the girl to whom he was already
engaged. He recollected having many strange ideas, e.g., he thought
that he was a cuckoo or a cow, and these he would imitate. He was
finally admitted again to Hospital, and, on admission, was intensely
confused and emotional, with complete loss of memory.

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The nervous system showed the following symptoms:

(1) Giddiness in changing his position or raising himself in bed.

(2) Inability to stand with his eyes shut, a tendency to fall to

the left, and inability to walk on a straight line.

(3) Inco-ordination of the upper limbs.

(4) Defective sense of smell—first cranial nerve.

(5) Diplopia of right eye; paralysis of right external rectus

muscle—sixth nerve.

(6) Twitching of right upper and lower eyelids (third nerve).

(7) Squint; limitation of right lateral visual field; rotary, and

at times, lateral nystagmus.

(8) Deafness in left ear; bone-conduction nil ; eighth nerve.

(9) Superficial and deep reflexes exaggerated.

(10) Ankle and knee clonus, but no Babinski.

These symptoms undoubtedly suggested an organic lesion, but they
were due to toxic neurasthenia. With rest and general treatment he
improved, although his symptoms varied from day to day. Then one
night he had a very vivid dream—that he was falling to the ground in a
bright red flaming aeroplane. When I visited him in the morning he
told me of this and said that his memory had returned, and he was able
to relate in detail much of what had happened. Gradually he improved,
and he was eventually discharged and sent to his home. This case was
of fascinating interest, and much time could be taken up in discussing it
in detail, but I am convinced it was a traumatic psychosis with a toxic
neurasthenia, and it is certainly interesting as illustrating the extra¬
ordinary complexity of symptoms in such a condition.

Treatment.

The treatment of shell-shock, or rather of the sequelae of this
condition, is intensely difficult. Unlike many diseases, the many
obscure symptoms which are present cannot be lessened or helped by
actual drugs. And yet there is much that can be done. Nothing,
however, can be done unless we understand the condition with which
we are dealing, and it is perhaps this feeling of ignorance that is so
much against us—it causes hesitation and uncertainty, which is very
readily recognised by the patient. With the physician there must—
outwardly at least—be no room for doubt: he must be ready to attempt
to explain to his patient, and in as convincing a way as possible, that he
is the master of the disease, and in the treatment of such conditions
this is half the battle. I shall not deal with general therapeutic
measures : it is important that these should receive careful attention. It is
important also that the physician should deal most tactfully with any
bodily ailment from which the patient may suffer, remembering always
that carelessness in the recognition of this may be the means of losing

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the patient’s confidence, whilst undue attention to the ailment may be
the means of creating fresh and false impressions of its significance.
But there are certain therapeutic measures which perhaps may appear
trifling, but which are, in reality, of the greatest importance, and to
these I shall refer in more detail.

Sympathy .—The importance of sympathy cannot be over-estimated.
There must be shown towards the patient all possible sympathy, remem¬
bering always that to him the illness is painfully real. In the first few
interviews much will have been accomplished if the patient has
been made to realise that the physician feels for him in his suffering; and
never by word or look should he be given cause to infer otherwise. But,
with the sympathy, there must be firmness—that is to say, although
sympathy must be shown, he must be induced to face his illness in a
manly way, and impressed that even the most persistent of symptoms
will eventually disappear. Sympathy must be real, for unless the
sympathiser has an appreciation of the patient’s condition and can look at
it as he does, he cannot really feel with the sufferer. True, manly and
firm sympathy is, I hold, the greatest therapeutic measure that we have
in such cases. Its therapeutic action, however, is not like that of a
drug ; it is more—it is the action on sensitive nerve-cells. It plays upon
the emotions, creating in the sufferer a feeling of trust, and this has its
effect, for it almost forces him to unburden the “ subconscious ” : it gives
the physician a chance of getting well acquainted with the contents of
mind; it enables him to link up circumstances, and is the keystone to
all further treatment. I cannot lay too much stress on the importance
of doing everything that is in one’s power to obtain the patient’s con¬
fidence at the beginning. It has often been said that it is bad for the
patient to make him talk about himself, or his worries. But, I ask, How
can a physician rid the patient of his troubles without first of all
discovering what they are, and then discussing them with the patient ?
Without getting at the root of the patient’s trouble, it is quite futile to
tell him to cheer up, stop worrying, go and work, etc.

Secondly, isolation is of importance, and should be in the first in¬
stance always attempted. It removes the patient from many circum¬
stances which would be harmful. But occasionally it does not succeed,
and should never be persisted in when it causes worry, undue
annoyance, or a tendency to depression. It is also of importance to
explain to the patient why isolation is necessary—namely, to remove a
sensitive nervous system as far as possible from the ordinary worrying,
although perhaps trivial circumstances of life. Still, speaking generally,
isolation—more or less severe—is usually helpful.

Hypnosis and suggestion. —The efficacy of this method of treatment
has, I think, been established beyond doubt, but it is a form of treat¬
ment which must be used with great caution; it cannot be employed in

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a haphazard way, but must always be used with a definite object in view,
and with a full knowledge of what result is to be looked for. With
reference to this method of treatment there is nothing obscure.
Suggestion is the keynote of successful treatment, and, as I have already
pointed out, the soil upon which it is to be placed can first of all be
prepared by sympathy. Thus, to cure a mental state, we are not going
to employ drugs, but are going to attack this mental state by mental
methods. It is, in fact, the influence of one mind upon another.

Hypnosis has been used in several ways. It was extensively employed
in the acute cases to cure such conditions as mutism, etc., and in which
it answered admirably. It has been used alone to calm the patient
and bring about natural sleep. It has been employed to recall past
memories, make the patient live through his experiences again, and get
at the early points in connection with the illness. And it has been
employed as an aid to suggestion in patients who are so much obsessed
by their own beliefs that the physician cannot in any way influence them
—acting by breaking down resistance, and preparing the soil for sugges¬
tion. This method of treatment I have employed with considerable
amount of success, and, although I never had the opportunity of using
it in the early cases, I have used it in many others, and have been able
successfully to attack the more chronic conditions like paralysis and
contractures—the most difficult of all to treat. As a method of inducing
sleep hypnosis is most valuable; as an aid to suggestion its useful¬
ness is undeniable; and further, it has, I am certain, a distinct place in
the therapeutics of mental diseases when used with skill, discretion and
care. It has been said that it has no lasting effects, and is but a
passing stimulus, but with this I do not wholly agree. The treatment
must be persevered with and continued, and undoubtedly it can help in
the restoration to health of the long-standing and persistent cases of
shell-shock in a manner quite unrivalled by other means.

There is but one thing more that I would mention in detail, and that
is the persistent battle dreams, which are often so vivid and so difficult
to get rid of. Most people would say to the patient: “ Don’t think
about your experiences when you go to bed.” Well, this is entirely
wrong, for the impressions become buried in the subconscious mind,
and then come into the conscious during sleep. The patient should be
told that, after he is in bed, he should carefully write out and read over
the dream that has troubled him, and you will find that if this is done a
few times the dream will disappear altogether. This certainly is my
experience.

This does not, however, exhaust our methods of treatment; we have
still one other which must be mentioned, although it is but an accumu¬
lation, a gathering together of all our means of treatment, and making a
combined attack on the mental state, the mental life, past and present, of

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the individual, using what means we can to get right to the bottom of
an almost unfathomable condition, building up and pulling down,
cleaning out and renovating, so that everything is cross-examined, every
symptom correlated with its casual facts. And such a method of
treatment we call “ psycho-analysis.” It is, at least, my conception of
psycho-analysis, and is really a breaking up of a mental state into the
component parts, understanding each part, so that they can be fitted
again with accuracy just like a jig-saw puzzle. Anything out of place is,
therefore, readily recognised, and re-education can be attempted.

The treatment of psycho-neuroses is no simple matter. Probably it
is just about the most difficult kind of treatment in the whole of
medicine. And why? Because we are dealing with that noumenon,
the mind, by which we think, we feel, and we act. Obscure and
numerous are the laws which govern our inheritance, and equally so are
those which lead to the transformation of matter into mind. It ill
becomes us to be dogmatic about anything in connection with
psychology, but there is one thing that I am certain of, and it is this :
that in the treatment of all mental cases, be they psychoses, neuroses or
psycho-neuroses, it is essential that the physician should be a man of
calm, thoughtful and sympathetic nature, and of sound common sense.

(*) A paper read at the British Medical Association meeting (Scarborough
Branch), December 10th, 1919.—(’) Ref. Brit. Med. Journ., November, 1910.

Reform of the Penal System in Scotland .(’) By James E. Shaw,

D.L., Hon. Sheriff Substitute, County Clerk and Clerk to the Ayr
District Board of Control.

Apologia .—In presenting this paper I must crave indulgence. I feel
rather in the position of an inexperienced player who, from a spirit
of good nature, has been induced to “ make up a ‘ four ’ at bridge.”
He will be lucky if he does not find at the end of the game that his
good nature is taken less into account than his presumption.

It is not my design to deal exhaustively with this subject, which is far
too wide in its scope, too complex in its nature, and too important in its
character to be brought within the scope of a short paper, I propose to
submit for your consideration one or two alterations of our penal
system in Scotland which may be more or less far-reaching, but which,
with your forbearance, I hope to show by consecutive reasoning to
be at least worthy of serious investigation.

The subject .—The subject may be gruesome, but in this respect does
not so much concern the members of this Society as some of our
clients ; it is of interest to the theoretical lawyer, who may like to trace

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the principles underlying the constitution of a penal code from the days
of a nomadic existence through various stages to present-day commercial
and social life; it is not devoid of humour and is full of romance, but
withal practical from the present-day point of view; and it is from this
aspect that I propose to review certain circumstances of the penal
system in Scotland.

The object of a penal code or system in all well-regulated countries
ought to be primarily for the prevention of crime, and to establish pro¬
tection from crime to the community, and only incidentally as a means
to these ends to provide suitable and relative punishment for crime, on
conviction before a competent, fair and upright tribunal.

The punishment should not be vindictive, or designed and put
into effect in such a way as by hurt or injury to the criminal, in body,
mind or estate, to satisfy thereby the vengeance of the outraged person
or public. It should not amount to mere retaliation, which in itself
injures the avenger no less than the avenged. The punishment should
be educative or instructive, to the extent, at least, of showing that the
game is not worth the candle, and thereby teaching the criminal that it
is to his advantage to cease from crime, as well as to cause the potential
criminal to abstain. It should also be curative, whether by supplying
the want, removing the defect or changing the circumstances under
the influence of which the crime is conceived and committed.

When looking back upon the horrible and revolting punishments
inflicted upon criminals in Scotland within the comparatively civilised
period of the last two hundred years, one is forced to the conviction
that our worthy old jurists were bent upon vieing with the vengeance of
the Almighty as depicted in the Old Testament, and came out of the
contest with flying colours ; or, alternatively, that nothing but the most
severe measures would knock sense into the heads of the hardened
sinners of that day and generation and deter them from crime. The
keynote of the penal laws of that period, which in the main were
remarkably sound, was undoubtedly revenge—an eye for an eye—nay,
probably two eyes, e.g ., in hanging a man for stealing a sheep. I am
one of those who consider that a great deal of harm is being done
in the present age by a silly, sloppy sentimentality; but I think there is
room for a great deal of improvement in the existing methods of
discovery of crime, the detection and trial of criminals and the treat¬
ment of convicts.

Of recent years there have been immense advances towards the
perfecting of our penal system on the lines indicated; and before
discussing proposals for the removal of existing blemishes, it is
well worth while to examine the very able writings of some of the
modern controversialists, among whom I should like to mention
more particularly the late Dr. Charles Mercier. It appears to be

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constitutional in such writers to set aside ruthlessly the theories of their
predecessors as “unwarrantable in assumption, loose and inaccurate of
thought, vague of description, superficial of observation, and dogmatic
in assertion of absurdities as incontestable truths.” This leaves very
little to be said in the way of caustic criticism. But I, being of a more
enlightened school, prefer to accept and adopt each in their turn as
advancing the movement at least one step, and, building on their
foundation, to add my stone to the structure, well knowing that we are
yet far off the completion of the edifice.

Crime .—Crime is the commission or omission of any act whereby is
constituted an offence punishable by law. Every act or action of life
is instituted by two essential factors, the one internal, the other external.
This is true of all vegetable, insect and animal life. The internal is in¬
herent in its kind, while much more potent in some individuals of the
same species than in others. But all of the same species are to some
extent possessed of the same inherent characteristics. The external
factor may be persistent and cumulative, and will accordingly have
some influence in developing or diverting the inherent qualities, or it
may be only incidental and temporary, so as to provide an opportunity
for the exercise of an inherent ability. The external factor will also
vary in intensity and in the influence it will have upon any individual
of the species, but both the inherent and external qualities will together
and in combination to a varying degree influence the actions of any
individual under any given circumstances. This principle must apply
equally to every act, including a criminal act.

The internal factor may be called heredity or original sin, or any
other term, but there is undoubtedly an inherent ability to commit
crime in every human being, which requires the external factor intro¬
duced as a partner to enable the crime to be committed. The hereditary
or original or inherent instinct will be influenced by moral upbringing
and surroundings or habits acquired in early life. The external factor,
whether called environment, free will or some other phrase, is dependent
upon outside influences, such as motive, temptation or opportunity,
which will affect the actions of any individual in direct ratio to their
force upon the inherent quality of that individual. To cause a crime
to be committed, therefore, it is necessary that there should be a strong
inherent propensity, combined with slight outside influence, or slight
inherent combined with strong outside influence. An extremely
criminal mind will be influenced by very slight motive, yield to slight
temptation and probably make its own opportunity; whereas an upright
mind would require the incentive of a powerful motive, combined with
an opportunity which would in itself amount to an overwhelming temp¬
tation. The extent of motive plus temptation plus opportunity plus
inherent proclivity in varying degree being the necessary combination

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to constitute a criminal action should, therefore, be taken into account
in assessing the extent of turpitude or baseness of the crime.

The criminal .—It is a common mistake to speak of “the criminal
classes ” when meaning the submerged class. We know that crime
permeates all classes, that every human being is born in original sin,
and we have seen that in each and all of us there is an innate dis¬
position to crime which only requires a sufficiently powerful motive,
temptation and opportunity to complete the combination for effective
crime.

In early days, as appears from the Hebrew and Ancient Greek
writings, there was a very general distinction of the people, families or
tribes into the good and the bad—the sheep and the goats—and whole
families or tribes were ruthlessly decimated as unrighteous. This may
have been due to the paramount importance in those days of racial or
sexual proclivities, in crime, which having an adverse effect on the pro¬
gress of the race, must be stamped out like swine fever in pigs, and very
much by the same method. From that idea of propitiating the anger
of God by cutting off all wrongdoers, through various stages we come
to the view that it would be wiser by fear of punishment to deter the
potential criminal than by exterminating the race or family to which he
belonged, and the punishments determined upon were such as to leave
no room for doubt as to their being fearsome. From that it was an
easy stage to the opinion that the punishment, while primarily a deterrent,
should also have some effect in reforming the criminal so that he would
not fall again. Subsequently came the Italian School, with the rather
grotesque but attractive teaching that the poor goats could not of them¬
selves help being goats, and it was evident from their appearance they
were goats and not sheep. That, indeed, proclivity to certain crimes
could be detected in the physiognomy of the criminal, in the shape of
the skull, the thickness of the hair, the size, shape and position of the
ears, number of teeth, and so forth. Their habits also disclosed their
criminal propensity, and that they were in fact degenerates, and should
by education and treatment be reformed. It is not recorded that as a
result of the education or removal of motive or temptation or oppor¬
tunity, when any successful reformation was attained, the physiognomy
of the individual was effected so that the shape of the skull altered, the
hair grew or ceased to grow or the ears changed in shape, but that did
not disprove the theory. As a result probably of the extravagance of
the last-mentioned theory, the next line of argument veered round to the
extreme opposite—that crime was to no extent due to inherent quality, but
solely to environment, such as faulty or deficient education, dissolute
parentage and squalid surroundings; and that with good drainage,
education authorities, proper housing schemes and prohibition of the
liquor traffic, crime would disappear. It seems to have been overlooked

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that crime does occur in the highest circles and among the most erudite,
though possibly, owing to motive and temptation being less insistent,
the inherent quality is less frequently invoked. Then comes the theory
that all criminals are insane—insane because they are criminals, and
criminal because insane, which cannot be accepted as useful or prac¬
tical in the result to which it leads. This is followed by a theory which
seems to be based upon Mendel ism—that a certain definite fixed pro¬
portion of the population are criminal, which was arrived at after a
most painstaking examination of statistics, and we all know the value of
statistics. And now we arrive at the latest doctrine propounded by
the learned and logical Dr. Mercier, that the “criminal act is due to
temptation or opportunity as the environmental factor acting upon
predisposition.” It seems a mistake to exclude motive as one of the
external factors, because, while some crime may appear to be without
motive, it is by no means usually so.

The general criminal is a rara avis. For the most part criminals
specialise in some particular class of crime in which they become more
or less adepts, and are known for their style and capability of execution.
In this they are no doubt guided by training and upbringing, e.g.,
mechanics to burglary, solicitors, financiers and such-like to fraud,
artists to counterfeiting, fishermen to smuggling and wrecking; and
having adopted a speciality, they seldom if ever depart from it. It must
have occurred to many of them as well as to onlookers that the same
amount of thought and energy applied to an honest calling would com¬
mand more fruitful results. An inordinate selfishness of character,
devoid of any higher ideal than immediate personal gratification, and
the want of sufficient self-control, are probably the most prevalent causes
of a career of crime. A distinguished student of humanity tells us that
“ there is no character which has not some redeeming points; pure
unmixed wickedness is the creation of romance, but never yet appeared
in real life,” and he very closely examined an extensive period of real
life. He gives as an example the unlikely case of Burke, who was tried
in 1828 for three cold-blooded murders perpetrated under repulsive
circumstances, and who no sooner heard the verdict of the jury which
found him guilty and acquitted his associate, a young woman who was
tried along with him, than he threw his arms around her neck and
kissed her, saying, “ Thank God, Mary, you are saved.” The writer
whom I quote, and who conducted the prosecution on the part of the
Crown, records his wondering at the time “ how many of his judges,
jury or accusers in similar circumstances would have done the same.”

Discovery of crime and detection of the criminal .—In the prevention
of crime a most important consideration is that it should be rendered
an unprofitable pursuit, and this can best be accomplished by making
the discovery of crime swift and the detection and conviction of

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the criminal sure. No one will commit a crime for gain in face of the
practical certainty of being immediately discovered and losing the
advantage which the crime was intended to confer. Misdirected energy
will not go so far as this, with the attendant disadvantages. When
Solon was asked which was the best policed city he replied, “ The city
where all the citizens, whether they have suffered injury or not, equally
pursue and punish injustice.” This is perhaps rather far-fetched, but
certainly all citizens in this country might contribute towards the result
to a greater extent than they do. Very few will submit themselves to
the inconvenience of informing except under the influence of excite¬
ment, and in view of the appalling conditions to which they are sub¬
jected in the average police-court they are scarcely to be blamed. They
might, however, bear the irritation of an effective registration system, to
which they would very soon become accustomed, as a necessary evil for
their protection. It is disconcerting to find that in only about 15 per
cent, of indictable offences reported are convictions obtained, and, if this
is correct, it leads one to suppose that the proportion of convictions
to crimes committed is very small indeed. Such a state of affairs almost
amounts to an incentive to crime. It has been shown that all are
potential criminals, and that previous conduct gives an indication of
the probability of lapsing into crime, also that criminals specialise in
particular classes of crime which they carry out with very pronounced
individual characteristics. As a matter of fact, experienced detectives
recognise the craftsman by his method of procedure, pretty much in the
same way as a writer is known by his style of writing or a tradesman by
thJ'IV.iracter of his work. Accordingly, with the help of a complete
and satisfactory register kept reasonably up to date, with a proper record
of crimes and a skilful classification of known criminals in frequent
circulation, detectives should be able to drop on the individual wanted
with incredible promptitude and certainty. I do not know how far such
a system may be already in operation, but it is certainly not in full and
complete operation. I know that it has been successfuly tried to a
limited extent in England, and the identifying marks are class-word,
entry, means, object, time, style, tale, pal, transport, trade mark.

The assize .—The trial is perhaps the most important link in the whole
chain of the penal system, and at the present day it may be said to be
the weakest. As an amateur judge of some years’ standing, I hope I
may be free of envy or disloyalty when I say that such judges as
honorary sheriffs, justices of the peace, baillies, etc., should be entirely
swept away; but I would bring them back in another form. There is
no sound reason why minor crime should be dealt with more loosely
than major crime, but rather as the minor offence is generally the first
step in that loss of self-control and giving way to inherent criminality
which leads to the establishment of an apprenticeship, culminating in
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some speciality of crime, it is all the more important that minor crime
should be tried with the greatest possible care and by a thoroughly
competent judge. For this reason I think there should be constituted
a sufficient number of stipendiary magistrates, but not necessarily drawn
from the Faculty of Advocates. Also, with a view to avoiding that
fruitful source of the creation of criminals, viz., the wrongful conviction,
should there not be a public defender as well as a public prosecutor ?—
a lawyer of equal standing and experience as the public prosecutor, who
by constant application to one special subject would become expert
therein. The accused would then have the best available line of defence
adopted for him, and incidentally the time of the Court and the public
purse would be saved. It is not suggested that an accused should not
be permitted to engage his own pleader to supersede or assist and
superintend the public defender any less than an accuser has power to
prosecute on his own account, but that a public defender selected for
his ability should be available, and in practice it would become as rare
for the accused to defend by private agent as it is for the accuser so to
prosecute. A common experience in trials which has struck me as
peculiarly inept is the way in which the judge who is a lawyer is called
upon to decide technical questions altogether outwith the scope of the
law. It may be said that he has the advantage of expert advice given
in evidence, but he has often to decide between the conflicting evidence
of experts on a subject of which he can have very little knowledge, and
if the evidence does not conflict there seems to be no reason why he
should hear it at all. Take, for instance, the very ordinary plea of
insanity. This is a purely medical question, and should be decided by
doctors. It has been laid down that a man of forty years is either a
doctor or a fool. All our learned judges are over forty, and none of
them is a fool therefore each is a doctor. But this is not quite good
enough to depend upon in a crisis. The procedure, as is well known,
varies according to the degree of insanity, the gravity of the crime, and
whether the defender or the inspector of poor is prepared to incur
expense, also whether the panel is not called upon to plead, or the case
goes to a jury to decide as to the panel’s sanity at the time of the trial or
at the time of committing the crime, all at the discretion of the prose¬
cutor. There seems to be no good reason for this variety in procedure.
The question before the House is that the prisoner is insane. This
should be determined by medical experts, and the prosecutor should
have no discretion in the matter. The present procedure very often
puts the cart before the horse, causes a great deal of useless expense,
and sometimes inflicts much avoidable cruelty. A client of mine in
good circumstances, a retired naval officer of eccentric habits, after a
protracted and painful illness brought on by financial worry got up
from bed and shot his wife. The gun was then taken from him, but

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he intimated that it had been his intention to shoot his son and the dog
and cat before shooting himself, and possibly the hens if the ammuni¬
tion lasted, but he was not sure about them. He was dragged from his
sick bed and placed in a police cell. The following day he emitted no
declaration, was examined and certified insane by the police doctor and
a mental expert on removal to the prison at Ayr. He was there
detained for four months until removed in sight of the public from
Ayr to Duke Street Prison for trial in Glasgow, and suffered what to
him was the greatest indignity, removal in Black Maria, “herded with
common criminals,” from Duke Street to the Justiciary Court
for trial. The plea in bar was accepted on the evidence of the two
doctors mentioned, being the only doctors who had examined him, and
the usual order was issued. I immediately made application to the
Secretary for Scotland, with the necessary guarantees, that he might be
removed to an ordinary asylum, and asked that he be retained at Duke
Street while the petition was being dealt with to avoid the removal to
Perth. The answer received was that the Secretary for Scotland did
not consider a prison a suitable place to retain a lunatic. I agree, but
remark that he had already been four months in prison after being
certified. He suffered a short sojourn at Perth before removal to an
ordinary asylum, where he died. Is this not a shameful instance of
unnecessary expense and trouble ? Another client of mine, who was a
known epileptic from his youth up, under stress of motive, opportunity
and temptation became a poisoner. The crime was cunningly devised,
and the extremely able council retained for his defence determined not
to plead insanity, as he hoped to get him off. The case went to trial,
but fortunately no doubt for friends and relatives, the jury, on the
instructions of the judge, found him insane, and he also died' in the
asylum after a visit to Perth. Surely this was a medical question, and
not one for council, judge or jury. Consider the danger involved had
the jury not so decided. Lastly, in a recent case a man was tried for
murder, with all the pomp and circumstance, not to say expense, of a
Circuit Court. No plea in bar was tendered, and the medical evidence
was as to the effect of alcohol on the actions of a man who had suffered
from malaria. He was convicted and sentenced to death, with a
recommendation to mercy, and a petition for reprieve was lodged.
Then, and not till then, was the man medically examined by mental
experts. A retired Commissioner in Lunacy, sent up from England,
along with a junior Scottish Commissioner, examined the convict, and
on their report the man was reprieved. And this after all the expense
and trouble of a Circuit Court.

My suggestion is that no technical question such as insanity should
be decided by a judge or jury, but should be referred to expert arbitra¬
tion, with a technical expert as referee in the event of disagreement.

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Thereafter, if the report of the referee, whenever such a reference is
necessary, does not bar the trial, the questions of fact and law should be
tried by a judge to decide whether the indictment is proved against the
panel. Further, that no one man should have power to inflict punish¬
ment upon another, and if the judge determines that the panel is guilty,
a jury or committee of responsible citizens of good moyen and estate
should, after hearing parties, and on the facts found proved by the
judge, determine the punishment according to the extent of turpitude,
taking into consideration motive, temptation and opportunity, as well as
any other circumstances that weigh with them.

Treatment of convicts .—We have seen that crime is largely misdirected
energy due to an external influence acting upon an inherent capability,
and that the treatment or punishment for this crime should be curative,
as well as being designed for the protection of the community from
crime and the prevention of crime.

Let us therefore abolish the existing punishment of penal servitude
and imprisonment as barbarous, and only tending to harden the
criminal instinct among those who survive, as useless for the purpose
for which it is intended, wasteful in expenditure and hopelessly
inappropriate. Let us rather guide and make use of the energy that is
misdirected in crime by first restoring the damage it has done, and
thereafter allowing the criminal, under proper supervision and control,
to make good for himself as well as for others.

The jury or committee for the punishment of criminals, in view of
the considerations above mentioned, would, in the first place, assess the
damage caused by the crime for which the criminal should become
responsible, allowing him a living income from his earnings; then,
according to circumstances, they would award a varying period of police
supervision and degree of frequency of report. With a proper registry
system there should be little difficulty about obtaining employment and
encouragement to lead a normal life in suitable surroundings to the
benefit of the State, and so save the convict from “a most dangerous
downfall, whereby the devil doth thrust them either into desperation
or into wretchlessness of most unclean living, no less perilous than
desperation.”

I can hear doubters suggesting the difficulty of engaging a murderer
as process clerk, a fraudulent cashier or a burglar as conveyancing
clerk. But how much do you know of the inner life of your clerical
staff, their inherent disposition, their motives, ambitions, temptations
and opportunities ? Remember that, as all criminals would be medically
examined, those having no power of control would be eliminated.
There would, of course, be lapses, and these would be punished by
closer supervision and more frequent report. If the lapses became so
frequent as to point to total incorrigibility, his employment in useful

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1920.] BV JAMES E. SHAW, D.L. I 5 I

work would become impossible, and then the criminal must be cut off,
washed out entirely, and no time wasted upon ineffective imprisonment.
He is better dead, for himself and for others.

I feel that such a system requires much more development and
elaboration before it can be made quite clear and intelligible, but it is
the fashion of the day to evolve schemes for renewing the earth without
clearly and explicitly stating how they are to be carried into effect. If
I adopt the fashion, it is not because I have failed to work out or study
the details, but because it would be monstrous to further encroach
upon your indulgence.

Conclusions.

(1) That a general register of the people be compiled and kept up to
date, together with a special register and classification of criminals to be
circulated among police forces.

(2) That a public defender be attached to every criminal court as well
as a public prosecutor.

(3) That stipendiary magistrates be appointed in substitution of all
honorary judges.

(4) That medical referees be attached to all criminal courts to examine
and report upon all criminals when necessary, anterior and as a pre¬
liminary to the trial on fact and law. This might be extended to all
technical questions that might arise, e.g ., engineering, shipping,' mining,
finance and others.

(5) That the decision of the judge be confined to the elucidation of
evidence and findings in fact and law to determine the guilt of the panel
as charged.

(6) That a jury or committee be appointed to assess the damage and
determine as to the treatment of the convict.

(7) That the existing punishments of penal servitude and imprison¬
ment be abolished, and a carefully-thought-out scheme be instituted to
enable the convict in the first instance by the fruit of his work to restore
the damage done by his crime, after maintaining himself, with a view to
his eventual restitution to all civil rights and liberty.

(8) That those criminals who prove incorrigible be destroyed.

(') Paper read to the 35th Annual Meeting of the Incorporated Society of Law
Agents in Scotland, October 23rd, 1919.

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Occasional Notes.

Progress of Psychiatry in England.

After reading the remarks of the Lancet for March 6th, 1920, under
the heading, “ The Reproach of Psychiatry in England,” it is with some
diffidence that one speaks of “ progress of psychiatry in England.”
Yet progress there has been, sporadic and intermittent it is true, but
nevertheless progress. “ Backwardness ” as regards psychiatry is rather
relative than absolute, and is not applicable to the whole subject, but
limited to scientific teaching and organised research. There are
few or no indications in those countries which are reputed to be
“ forward ” in this branch of medicine of more success in treatment,
especially in the permanent cure of either early or established cases,
while no country surpasses this as regards the care and accommoda¬
tion of those mentally afflicted. The general view of English psychiatry
—and one not without some foundation—is that much of the progress
of psychiatry so well boomed as occurring abroad and not at home
ends very largely in paper, verbosity, and high-sounding terminology,
and the attitude taken up is in large measure that of the critic and sceptic.

It must be admitted, however, that, after all has been said, the
remarks of the Lancet , as far as they go, do not incorrectly describe the
situation, and we are bound to admit that a reproach exists. Happily
there are at present signs and symptoms of a great awakening in this
country to the needs of psychiatry, and let us hope that, though delayed,
the progress foreshadowed will be solid and durable and attain the objects
in view, i.e., the definite entry of the treatment of mental diseases
and the cure of insanity into the current practice of medicine. Too
long have the insane been considered a class of people needing mainly
separate care and special segregation, who only resume their full
citizenship on recovery. No doubt such has been necessary in the past,
and perhaps the only way, and the benefits that have come to them
thereby are undeniable. Daylight now enters freely the institutions for
the insane, humane treatment is uppermost and they are administratively
admirable. Progress in this direction would appear now to have
reached its limit in this country, and the high degree of efficiency
attained is not a reproach, but the opposite, and we can afford to some
extent to rest on our laurels in this respect.

The time has come to turn our efforts rather to the removal as far as
practicable of the insane from their traditional sectional treatment, con¬
sidering them merely as patients suffering temporarily or permanently
from one of the ordinary current diseases and disorders. Along these
lines must future progress be made. To further this the mental hospitals
need to be linked up with the hospital system generally, and psychiatry
more closely interwoven with ordinary medical and hospital practice.

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The first step in this direction was the creation of the trained mental
hospital nurse, and the second the establishment of psychiatrical train¬
ing for doctors and diplomas in psychological medicine. The war has
retarded matters somewhat, but this has not been without its advantages,
since methods of care and treatment have been rendered possible which
undoubtedly will make their influence felt in the future.

At the last quarterly meeting of our Association, reported in this
Journal, reference was made to the pioneer work of the special com¬
mittee which came into being as the outcome of a communication by
Colonel D. Thomson on post-graduate teaching and training in
psychiatry in 1908. The result was the establishment of diplomas in
psychiatry and psychological medicine by the Universities. It was
decided that the time has come now for further progress in this direction,
and a committee was instituted, having for its reference—“ To consider
the best method and facilities for training in psychiatry and for
obtaining the diplomas which exist.”

In a recent paper read before the Association, Dr. C. Hubert Bond
advocated the establishment of mental cliniques at the general hospitals,
and closer relationships between the mental hospitals and the general
hospitals as regards teaching, research and treatment. This paper by
Dr. Bond was a well-timed stimulus to action, and the Association
would be betraying its trust if it did not take energetic steps to further
the proposals made. It has definitely done so by the appointment of
this special committee, for both these matters are indissolubly bound
together.

Too long has psychiatry been in a great measure isolated from
general medicine and left to struggle alone. The cure of mental
diseases is in actuality the most difficult problem which for ages past
has faced the medical profession, and a problem which calls for the
application of the acutest intellects in our ranks for its solution. Not
that psychiatry has not now, as in the past, illustrious men entirely
devoted to it, but its very complexity demands the greatest efforts
possible of the profession. Until a person who has become afflicted in
mind has a reasonable prospect of a speedy and permanent cure the
public will be dissatisfied and a reproach will remain.

We work under many difficulties and disadvantages which must be
capable of some solution. The great drawback has been the difficulty
in obtaining a steady flow of the best men from the hospitals to the
asylums and the practice of psychiatry in general. The heads of the
profession have not always been with us, and have been often even
against us. Administrative and clerical work, very ordinary medical work
with little or no surgery, and general professional stagnation have been
the gravamen urged, and this is the real sting of the reproach. How far
it is true or otherwise the members of the Association know, but it

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OCCASIONAL NOTES.

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should be remembered that medical administration, under the en¬
lightened control of the many lay committees, has in any case raised
the mental institutions to their present high level of efficiency.

Medical administration has been necessary in the past, and always
will be. The trouble is that administrative duties and responsibilities
increase as juniors become seniors and seniors become medical super¬
intendents, with the result that as medical experience increases in value
to the patients, the opportunities for concentration on purely medical
work decreases, until, in the case of the medical superintendents, it is
often almost entirely crowded out by administrative duties. Progress
in the treatment of mental diseases necessarily suffers, and will do so so
long as matters remain as at present.

Some reconstruction and rearrangement of the medical and admini¬
strative work in the mental hospitals would appear to be imperative if
the full benefits of the psychiatry and research work of the future are
to accrue to the patients. It is neither possible, nor is it the place, in a
short “ occasional ” to deal adequately with the matter; but there appear
to be three fundamental principles which, we venture to suggest, should
guide the Association when the time comes to formulate its views :

(1) The responsibility for the management of the mental institutions
is a matter for local authorities and committees and their medical and
other advisers.

(2) The care, custody and cure of mental patients is a national and
not a local responsibility, and should be in the hands of a medical service
subject to Parliamentary and not local control.

(3) The duties and responsibilities of local authorities and the
medical profession should be allocated in accordance with (1) and
(2) in order to secure the carrying out of (2).

In conclusion we desire to offer our congratulations to the London
County Council and Sir Frederick Mott on the completion of the
scheme for the giving of lectures and practical instruction in psychiatry,
rendered possible by the enlightened views and generosity of the late
Dr. Henry Maudsley, who, it is regretted, did not live to see either the
Maudsley Hospital completed or be present at the opening of the first
session of London’s great school of psychiatry. Sir Frederick Mott’s
words, written in the Archives of Neurology for 1907 and quoted by the
Lancet {see p. 558), are bearing good fruit, and generations of students
to come will have good reason to be grateful to him for the prominent
part he has taken in the genesis of the Maudsley Hospital.

Studies in Mental Inefficiency.

We have received the first number of this new publication, which is
issued by the Central Association for the Care of the Mentally Defective.

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1920.]

This Association has already done work of considerable social value,
and this publication should not only serve to give greater publicity to
its aims, but it should become an educational medium of great usefulness
to the increasing number of the public who are concerned directly or
indirectly with the problem of mental deficiency. The journal should
supply an obvious need. Hardly sufficient interest is shown by the
public in the sociological problems included under the wide term
“mental inefficiency”—the criminal, the mentally deficient and the
insane—and this publication may do much to stimulate interest in
these directions. It is starting in a modest way and we wish it every
success, and we may perhaps express the hope that it may so receive
the support of the medical profession by contributions of interest and
value, and that of the public by subscribing to it, that it may eventually
attain the importance and dimensions as have journals with similar
aims in other countries. The opening number has the advantage of a
sympathetic foreword by Dr. Shuttleworth, who has done so much for
the mental defective, and it includes interesting papers by Dr. Tredgold
and Miss Fildes.

Part II.—Reviews.

The Autonomic Functions and the Personality. By Dr. Edward J.
Kempf. Nervous and Mental Disease Monograph Series, No. 28.
New York and Washington, 1918. Royal 8vo. Pp. 156. Three
Illustrations. Price 82.

Most of the readers of this journal will recollect how scanty was the
attention paid in their student days to the study of the sympathetic
nervous system. It was deemed to be of little account except in so far
as it influenced the action of the heart and the processes of digestion.
Compare with this neglect the amount of instruction given in the
anatomy and physiology of the cerebro-spinal system. And this state
of the case in the medical schools was but a reflection of the literature
of the day.

Times have changed, and there now appear in bewildering succession
books and articles on what some call the vegetative, others (including
the present author) the autonomic system. The book under considera¬
tion deals, then, with the autonomic or sympathetic system, and it is
written to show the enormous effect this system has upon the behaviour
and personality of man. It is divided into four parts. Part I is mainly
anatomical; Part II, physiological; Part III deals with the psychology
of the matter, and Part IV is a brief recapitulation.

Whatever may be the exact views held as to the relationship between
mind and matter most of us cling to the general idea that the seat of
the mind is the brain. The theories of our predecessors that the

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heart, the liver, and other viscera had to do with the emotions are
regarded with an indulgent smile as belonging to antiquated thought.
It is a considerable shock therefore to be told in a modern book that
ours is an “ old notion ”; that the sole reason for the idea of the mind
being situated in the brain is the fact that the eyes and ears are set in
the head. So says the author of this book. But the mind, where is
it ? He replies: “ In the autonomous system.” The autonomous
system is the lord, the cerebro spinal, the humble servant who merely
obeys his master’s bidding.

Professor James had partly prepared us for this revolution by his
theory of the origin of emotions, but Dr. Kempf goes further, and in
his opinion not only emotions but desires and thought are due to
changes in the sympathetic nervous system.

There is naturally a considerable amount of resistance to be over¬
come before such teaching can be seriously entertained, but Dr. Kempf
argues his point of view with considerable courage and erudition. His
book is worth reading for the manner in which he has collected and
collated the experimental work of Sherrington, Cannon, Crile and a
large number of other writers. As regards his psychological outlook he
is an ardent follower of the teaching of Freud, and from another point
of view this book may be regarded as an attempt to show the physio¬
logical mechanisms underlying the psychological phenomena known as
repression, wish-fulfilment and the like.

It will be realised that adequate discussion of the problems men¬
tioned are impossible on the present occasion. With regard to minor
criticism it must be stated that in parts of the book the arguments
would have appeared more convincing had they been better arranged.
There is evidence of haste in writing, and some revision and reconstruc¬
tion will be beneficial in a second edition. To give one example :
“ Another confusing practice of some psychologists, that has been the
cause of considerable confusion, is the tendency to consider that an
emotion either exists or does not exist, and that it exists in the
personality by itself as a free agent that may attach or detach itself to
objects, people, ideas, etc.”

This is one of several passages marked as difficult to comprehend.
These, however, are small faults which can easily be corrected, and
on the whole Dr. Kempf is to be congratulated on his efforts to throw an
entirely new light on the workings of the mind and the personality of
man. R. H. Steen.

Sexualpathologie: Ein Lehrbuch fiir Arzte und Sludierende. By Dr.

Magnus Hirschfeld. Bonn: Marcus & Weber, 1917-18.

Parts I and II, pp. 211 and 279. 8vo. Price m. 40.

It is thirty years and more since Krafft-Ebing published the first
edition of his clinical and forensic study, Psychopathia Sexualis, and
although that work still continues to appear in ever-enlarged and
modified editions, it no longer corresponds to the present outlook of
scientific investigation. Dr. Hirschfeld, of Berlin, who possesses an
unequalled knowledge of the pathological side of sex, acquired during

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twenty years of special practice in this field, has therefore here made
an attempt to supplant Krafft-Ebing’s book as a manual for practitioners.
Two parts have already appeared.

The author has discarded Krafft-Ebing’s title. Sexual pathology is
no longer concerned only with psychic facts ; we have learnt how
intimately in this field the psychic depends on the physical, and Steinach
has shown how by simple transplantation of sexual tissue it is possible
to masculinise, to feminise, or to hermaphroditise an organism. It is,
above all, the new doctrine and the new knowledge of the internal
secretions which has revolutionised sexual pathology. Hirschfe'.d
remarks in the preface that the endocrinic doctrine is the Leitmotiv of
his whole book, to be heard in every chapter. But he adds that the
book is purely clinical, proceeding from a consulting room and not from
a study ; every case brought forward is from his own practice, and some
of them have been under observation for ten, fifteen, or even more
years. This personal character of the work has its disadvantages when
it is a question of a text-book for general use, for Dr. Hirschfeld is
sometimes negligent and even inaccurate in his references to the work
of other investigators, even when they bear most clearly on his own
work, but the positive value of the treatise remains little impaired.

The absence of the sexual glands and the results of their removal are
first dealt with, including eunuchoidism (or testicular hypoplasia), and
the various aspects of the subject of castration in males and females,
including the accidental castration (for the author finds no evidence of
intentional mutilation) occurring during the war. The next chapter
deals with infantilism, in what the author regards as its four funda¬
mental forms—genital, somatic, psychic, and psycho-sexual; inci¬
dentally cryptorchidism and dwarfism are discussed, as well as the
various aspects of pcedophilia erotica , in connection with which Hirsch¬
feld states (contrary to the opinion formerly expressed by others) that
he has never known an outrage on a child to be committed by a subject
who was not found on careful examination to be seriously defective
mentally. A varied and interesting chapter on precocity, considered
in the same four forms, is followed by a chapter on sexual crises.
This is a comprehensive discussion of the various psychic and nervous
disturbances associated with puberty, menstruation, pregnancy, and the
climacteric. The first volume concludes with instructive chapters on
masturbation, for which Hirschfeld (following Kurkiewicz of Cracow)
prefers the word “ipsation,” while (following Rohleder) he uses the
term “ ante-monosexualism ” for that variety in which the subject feels
a psychic attraction to his own body; there seems, however, no good
reason for abandoning the term “narcissism,” usually given to this
variety. Hirschfeld presents a curve, based on over 500 cases, showing
that twelve to fourteen is the most usual age (44 per cent.) for beginning
masturbation, and he considers that its prevalence in the two sexes is
about equal, though it tends to begin much later in women than in the
other sex. There is no reliable indication of masturbation and no
specific disorder connected with the practice. On these points he con¬
firms other recent investigations.

The second volume deals with those various intermediate sexual
stages, somatic and psychic, concerning which Hirschfeld is already a

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recognised authority and the author of several extensive monographs.
In these condensed chapters, richly stored with facts, he summarises
his earlier work and brings it up to date. The subject as a whole he
entitles “ hermaphroditism,” that is to say, the mixture of the opposed
sexual characters, or, as Orth put it, “ the confusion of sexual
characters.” Hirschfeld recognises four groups of hermaphroditism
and devotes one or two chapters to each : (i) Genital hermaphroditism,
until recent times the only form recognised; (2) androgynia, or the
general physical mixture of sexual characters ; (3) psychic hermaphro¬
ditism, or the mixture of psychic sexual characters, by Hirschfeld
named “ transvestism,” which seems too narrow a name, so that the
present reviewer has proposed the term “ eonism,” after the Chevalier
d’Eon, the most famous representative of the type; and (4) psycho-
sexual hermaphroditism, that is to say, homosexuality or sexual inver¬
sion, together with what Hirschfeld terms “ metatropism,” by which he
means an inversion of the ordinary tropisms of the sexes, the man
passive instead of active, and the woman active instead of passive.
This last division is new, and is based on the conception of Krafft-
Ebing that in men there is a normal tendency which has its extreme
pathological form in sadism, and in women a normal tendency with an
extreme pathological form in masochism. It is not probable that this
conception, in the formal and precise shape into which Hirschfeld
puts it, will be universally accepted. There are many female sadists
and more male than female masochists. It seems quite possible to
argue that the supposed general activity of the male and general
passivity of the female is largely a conventional notion based on
prevailing social modes, and not so deeply rooted in Nature as to be
true of all forms of male and female activity. It may be roughly true
of our current practical life and yet not be susceptible of conversion
into a fundamental biological doctrine.

A third volume, not yet published, will complete the work. When
thus completed, there can be little doubt that this text-book will prove
of much practical value, alike from the psychiatric and the forensic
standpoints. It should be added that the numerous illustrations are
of high quality and much interest. Havelock Ellis.

Dreams and Primitive Culture. By W. H. R. Rivers, M.A., M.D.,
F.R.S. Reprinted from The Bulletin of the John RylaruTs Library.
Longmans, Green & Co. Demy 8vo, pp. 28. Price is.

It must be admitted by even the bitterest opponent of Freud’s
theories and writings that they have stimulated research in other
matters which at first sight would appear to have little in common
with them. Thus, for example, there are books upon “ dreams
and myths ” and “ wish-fulfilment and fairy tales.” The subject of
the present review is a lecture which was delivered at the John
Ryland’s Library on April 10th, 1918, and it deals with the resem¬
blances which are to be found between dreams and the customs of
savage peoples. Much of the material has been obtained from study
of the Melanesian or Papuan cultures, and the greater part from the

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social life of the inhabitants of one tiny island only two miles in
diameter—“ Mota of the Banks group.” The lecturer deals with his
subject in the same manner as Freud describes the dream-work. He
takes up one by one the questions of distortion (here called “ trans¬
formation ”), dramatisation, symbolisation, condensation, displacement,
and secondary elaboration. He then goes on to consider the censor,
wish-fulfilment, role of sex, and finally the unconscious. Explanations
are made of the meanings of these terms, and illustrations of similar
processes are given as they occur in the primitive races.

For example: “ A native of Mota in the Banks Islands, who is
marking out a plot of ground which is to be the property of an unborn
child, carries a dried cocoanut under his left arm or on his left shoulder
as a symbol of his purpose.” On inquiry it will be found that the man
attaches great importance to this simple object, and regards its use as
essential to the proper performance of the work upon which he is
engaged. How foolish and absurd this custom seems to be, and just
as ridiculous as the manifest content of many a dream! Yet when the
matter is investigated scientifically it will be found that the cocoanut
represents the human head, and interwoven with this idea are various
beliefs regarding the soul, the danger and sanctity of the head, etc.
To use the terminology of dream-study, the manifest content of the
custom appears foolish while the latent content is full of meaning.

Dr. Rivers acknowledges his adherence to the dream-psychology ot
Freud. It is not to be understood that he follows the latter’s teaching
implicitly in all points, but in the main, and especially with regard to
the psychological mechanisms involved in the production of the dream,
he asserts his belief in the correctness of Freud’s work. He is further
of opinion that his studies in anthropology offer one more proof of this.
It is unfortunate that so much learning and research had to be com¬
pressed within the narrow limits of a lecture. So highly condensed
has the material been that it has been impossible to epitomise it in
any way with justice to the author. It is earnestly to be hoped that
Dr. Rivers on some future occasion will expand these few pages into a
book and so reach a wider circle. R. H. Steen.

Studies in Word-association: Experiments in the Diagnosis of Psycho-
pathological Conditions carried out at the Psychiatric Clinic of the
University of Zurich. Under the direction of C. G. Jung, M.D.,
LL.D. Authorised Translation by Dr. M. D. Eder. London:
William Heinemann. Pp. 575, demy 8vo. Price 25 s.

In the earlier work in psycho-analysis use was made of two methods—
“free association,” in which the subject tells all the thoughts which
come into his mind, avoiding criticism as far as possible; and the
interpretation of dreams. It was soon found, however, that in some
patients the associations came to an abrupt stop and that no dreams
were forthcoming. Dr. Jung suggested the use of the word-associa¬
tion test, and this has been generally adopted as a third means of
obtaining an insight into the mental state. He and his fellow-workers
published numerous papers on this subject which are scattered through

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periodicals in the German language, and we are indebted to Dr. Eder
for translating these and collecting them under the covers of one
volume.

It is, of course, most essential before discussing the use of any
method in abnormal people to have a clear understanding of how it
behaves in the case of the healthy. It is therefore not surprising to
find that more than one-fourth of the book deals with the associations
of normal subjects. A comprehensive table is given of Jung’s classifi¬
cation of reactions and the percentages of these met with in different
types of humanity with and without distraction.

Among the conclusions reached after experiments on normal subjects
are the following : (a) That reduction of attention through any kind of
inner or outer impulses makes the reaction type a more superficial one—
that is to say, the inner or higher associations recede in favour of outer
associations and clang reactions. ( b) Indirect associations are increased
when there is distraction of the attention. ( c ) The educated have on
the average a more superficial type than the uneducated. ( d ) As to
the degree of the dissociation of the attention caused by distraction,
there are no essential differences between the educated and the
uneducated.

Jung then proceeds to describe two types of mankind revealed by
the experiment—the objective and the egocentric. This work probably
laid the foundation for his ideas on the extroverted and introverted
varieties which are discussed in a later paper (“Analytical Psychology,”
C. G. Jung, translated by Constance Long, Chapter XI).

After the very elaborate discussions of the normal psychology there
are chapters on the use of the test in imbeciles, epileptics, cases of
hysteria and in families.

Scattered through the book are references to complex-indicators and
a short chapter summarising these would be welcome. For the benefit
of our readers they may be given as follows: (i) Increase in the time
taken to give a reaction. This is one of the most important signs and
is dealt with in detail in Chapter V. Sometimes the patient is unable to
give any response to the stimulus word within a reasonable time, say
half a minute. (2) The nature of the reaction. This may be super¬
ficial or even an apparently senseless one. The subject may not hear
the stimulus word aright, which will have to be repeated, or he may
himself repeat the stimulus word. At times the word given as the
reaction is used several times. This word may be given in a foreign
tongue and in an energetic manner. Frequently after a long reaction
time the immediately subsequent reactions are upset through persevera¬
tion. The whole behaviour of the patient must be watched and noted.
A foolish laugh or emotional disturbance may occur during the test
without any apparent reason. (3) On the completion of the test the
subject is asked to repeat his reactions and failure to do so is of
significance. This is dealt with in Chapter X.

Taking the book as a whole there is a sense of inequality in the
material provided, and it is suggested that several chapters might well
be dispensed with in a later edition without diminishing its value.
These remarks do not refer to those written by Dr. Jung, which are
always interesting and suggestive. It is certainly most instructive to

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have complete examples such as are given in Chapters VII and IX of
the use of the method by the designer of the same.

Even apart from psycho-analysis there can be no doubt that the
word-association test will occupy a more prominent place in the future
than it has done in the past. There are many possibilities of its value
in diagnosis and prognosis. This book will be indispensable to anyone
who wishes to make use of the method and should be in the library
of every mental hospital.

Considering the fact that the subject-matter deals with words Dr.
Eder had no easy task. He has used his discretion to introduce
more suitable English words when the literal translations of the original
words would have conveyed no meaning. He is to be congratulated on
the excellence of his work. A comprehensive bibliography is appended
and adds considerably to the value of the book. R. H. Steen.

The Daivn of Mind. By Margaret Drummond, M.A. London:

Edward Arnold, 1918. 16 mo, pp. 179.

If the perusal of this book will make the average mother take an
intelligent interest in the growth of her child’s mind it will serve a
useful purpose. Anybody who tries to find out why and how babies do
things is apt to be regarded as an unfeeling wretch since his endeavours
tend to correct the delusions which women cherish about their off¬
spring. As a consequence an important psychological field is left
almost untilled. The author of The Dawn of Mind , perhaps because
the children she describes are not her own, achieves a considerable
measure of detachment. Misgivings may arise as to her method if the
reader, on taking up the volume, should happen to open it at p. 25 and
read that “ Baby, like the wise little person he is,” does something or
other, and the frontispiece may strike him as futile, but these minor
blemishes convey quite a wrong impression of the book, which is really
full of sound sense and entitled to respectful consideration.

In a preliminary chapter some particulars of the nervous system and
its functions are given. The information is, no doubt, full enough and
accurate enough for its purpose, though it implies a simplicity about
the nervous organisation of the human body which is rather misleading.
The “ reflex wink ” does not seem to be a particularly happy example
of activity confined to “ the lowest level of neurones.” It supports,
rather, the view that reflexes are produced from volitional activities by
a process of degeneration. Speaking of the earliest stages of reasoning,
the author says—“ at first we notice likenesses rather than differences.”
The accuracy of this statement is open to question. The “likenesses”
which appeal to the infant mind are probably “ likeablenesses ” rather
than the resemblances which exist for the adult. In testing the intelli¬
gence of children it is found that the age at which they recognise the
differences between related articles, eg ., fly and butterfly, is several
years below that at which features of similarity are described. Speech
is treated of as wholly acquired, though it is noted that a child who
presents defects in his later speech “ may have made the required
sounds quite correctly in his baby prattle.” This fact, which has been

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recorded by other observers also, suggests that the first attempts at
speech represent an inheritance rather than an acquirement.

To the general teaching of the book only praise can be given. There
is, possibly, a certain quaintness about the proposition that a baby may
be too old at five, but the point made is a good one. In regard to the
education of children we are still far from the happy mean, and the
influence of fashion on methods of teaching is not helpful. It is
certainly much better to lets one’s pig trot to market rather than to
have to haul him there by the hind leg, but he must be supervised
sufficiently closely to prevent his bolting down the side streets, and the
complacent parent who justifies his neglect by the fatuous excuse that
“ you can’t put old heads on young shoulders,” is just as dangerous to
a child’s mental development as ever was the bigoted pedagogue of the
past. E. B. S.

Part III—Epitome of Current Literature.

1. Psycho-pathology.

The Psychology of the Normal Woman in Relation to her Crimes and
Passions: Her Peculiar Psychoses [La Psicologia della Donna
Normale in relazione ai snoi Delitti e alle Passioni; Psicosi sue
p ecu liar /]. (Arch, di Antropol. Crim. Psich. e Med. Leg., Sept-
Dec., 1917.) Lombroso , G.

It has been frequently observed that crimes committed by women
are usually of comparatively small importance, and that murder is
rarely committed by them. On the other hand, they have been known
to have become suddenly insane or to have committed atrocious crimes
from causes which were strangely disproportionate to the results. The
writer attributes these particular forms of criminality and insanity to
woman’s special emotionalism (passionalith), and the illogicality, exaggera¬
tion, easy vivification of inanimate objects, ideas of the importance of
dress, and enormous amourpropre which are derived from it.

Feminine emotionalism is distinguished from the masculine by the
fact that it always has for an object a living, concrete being—a father,
husband, lover, child, or even a dog or a cat. A woman is miserable
unless she has something to which she can dedicate herself, for which
she can make real sacrifices. This feminine altruism is necessary for
the preservation of the species. If the female were not provided with
it, the species would presently be extinguished. This ardent passion
for every living thing, which potential maternity develops in a woman,
is the primary cause of her minor criminality. She receives such pleasure
from the life around her that she has a profound repugnance to
destroy it.

One of the primary consequences, if not the cause, of the special
emotionalism of woman is her lack of logic. A woman is devoted to
others from instinct and impulse, not from reflection. This want of

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logic explains how crimes committed by women are often so absurd
and fantastic. A female criminal only exaggerates in crime a character
which is hers normally.

Another characteristic derived from the emotionalism of women, and
which reveals itself perhaps more in their suicides and psychoses than
in their crimes, is exaggeration. It is the cause of a woman’s irritability,
susceptibility and illusions. When life is tranquil a man simply enjoys
it without worrying about the past or future. But a woman does not
live in the present; she lives in the past or future, and is continually
tormenting herself about what may or may not happen. Before a girl
is married she is thinking of the evils which may befall her children.
When she is married and has a perfectly healthy child, she torments
herself about what would happen if he were to fall ill.

Women are endowed with an imagination which appears to have the
power of transforming the inanimate objects around them into living
beings, in which they confide, and which they love as real persons.
Mrs. Browning, George Sand, Juliette Lambert and Laura Thompson
spoke to the trees in their gardens, and in their letters they show that
they believed that the trees were sensible of their affection. This
power, which a woman has of vivifying the inanimate things around her
and of loving them as living beings, explains the passion with which
she resists those who would deprive her of them, and one understands
how it may lead her to falsehood and theft to preserve them, and even
cause her to murder without repugnance those who would take them
away from her. This feminine love for inanimate objects led Cesare
Lombroso to suggest more than once that the furniture should legally
belong to the wife.

The writer says that vanity has but little to do with a woman’s love
of dress. According to him, dress, ornaments, jewels are for a woman
the marks which demonstrate to the public, which does not know her,
her social class, her riches, the affection of her husband and relatives.
One observes that a middle-class woman displays all her luxury in the
street or in the theatre where the public, whose judgment is important
to her, looks at her and judges her; while the high-born lady dresses
modestly for the street, and reserves her elegant attire for the drawing
room or the dining room, where she finds the public whose approbation
she desires. A jewel or a beautiful dress is to a woman what a cross is
to a chevalier, or a medal to a soldier; they represent her rank. The
fact that dress represents so much to a woman explains how she will
often steal or commit other crimes in order to possess an ornament or
a beautiful garment.

Women attach enormous importance to the judgment of others.
This sentiment, improperly called amourpropre , often induces them to
risk personal injury rather than expose themselves to the disapprobation,
the sarcasm or the compassion of others. This is the reason for the
greater number of infanticides and of many other crimes such as the
murder of a lover who abandons or betrays his sweetheart. A woman
never kills the husband who betrays or abandons her, but she frequently
murders the lover who does so, because the last offends her amour
propre , and the first offends only her love.

J. Barfield Adams.

LXVI. 12

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Dr. Lattes’ paper includes detailed reports of the sixty cases, which,
though very condensed, are remarkably clear pictures of the mental
condition of each patient. A few of the cases give rise to suspicions of
simulation and malingering, but the majority were evidently genuine
attempts at suicide. J. Barfield Adams.

2. /Etiology.

Syphilis as an Etiological Factor in Epilepsy. ( Journ. Missouri Stale
Med. Soc., November , 1919 ) Booth , D. S.

The author prefaces his thesis by defining epilepsy on the basis of
entity, though calling attention to the fact that it is but a syndrome
resulting from many and various conditions, some known and discover¬
able by a thorough and complete clinical and laboratory examination,
others unknown and not discoverable even post-mortem by any means
yet known—so-called idiopathic epilepsy.

The author recalls that there is a variation between different observers
as to the frequency of syphilis as an /etiological factor in epilepsy, at
least to the degree that it is the sole cause—which is often difficult, and
at times impossible, to demonstrate. Though generally recognised that
epilepsy may be caused by various tangible syphilitic demonstrations,
most authors do not mention the possibility of syphilis causing a
“ basic impairment of the germ-plasm ” without pathological findings ;
however, it appears evident that there must be a peculiar condition of
the nervous system, inherited or acquired, that enables an irritant,
whether toxic or otherwise, to produce stereotyped attacks in certain
individuals and not in all having a similar exciting factor.

Most text-books merely refer to syphilis as one of the causes of
epileptic attacks without any reference as to its frequence or the manner
in which it acts.

Available statistics give syphilis as infrequent in epileptics—from 5 to
14 per cent. —while reports of most serologists give a small percentage of
positive Wassermann reactions in both the blood and spinal fluid, with
variable and inconstant findings in the latter as to pressure, pleocytosis
and globulin content, though frequently there is a considerable devia¬
tion from the normal reaction of the Lange colloidal gold test.

If it be possible for syphilis to be present in an epileptic without
giving any diagnostic evidence, it may be argued that the disease should
at any rate respond to antiluetic treatment, which is untenable, since a
disease or condition is not necessarily cured by treatment directed to
the cause; hence the fact that symptoms, presumably due to a frank
syphilis, do not recover after all clinical and serological evidence of
syphilis has disappeared, does not necessarily argue against a syphilitic
origin.

Another source of error arises from depending too much upon the
laboratory findings and too little upon the findings of a critical clinical
examination.

Though some of the author’s cases of epilepsy have shown only a
two-plus Wassermann and a few but a one-plus reaction, he is treating
them as though specific in origin with encouraging results, though it is

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too early to record conclusions. Those giving a one-plus Wassermann
have been almost entirely children or women, in whom he had reason
to believe that if syphilis were present at all it was hereditary.

While unprepared at this time to give data, the author states that in
his experience of the past several years the proportion of epileptics
giving a Wassermann reaction in some degree is much greater than
that given in available statistics, and he feels confident that the
laboratory has not detected all cases in which syphilis was, either
directly or indirectly, an aetiological factor. Author’s Abstract.

3. Clinical Psychiatry.

A Contribution to the Study of Toxicomania . . . on a Psychasthenic

Foundation ( Psyclio-toxicomatiia ) [Contributo alio Studio delle
Tossicomanie . . . su Fondo Psicastenico (Psico tossicomanie )].

(.Reprinted from II Manicomio, 1918.) Bianchini, L.

R. F. E—, a sub-lieutenant of infantry, was charged with cowardice
for having on November 1st, 1916, at the commencement of an attack
on the enemy’s position, deserted his company. The regimental surgeon
reported that the man was a confirmed morphia maniac, and that scars
of injections were visible on his body. The commander of his battalion
reported that he was intelligent, capable of service, but of a rather weak
physical constitution. The captain of his company reported that he
was ignorant of moral duties, had no sentiment of dignity or amour
propre , that he was a morphia maniac, and gave one the impression that
he was mad.

R. F. E— was the eldest and the least robust of a family of six, the
family history being good. At school and afterwards he showed himself
fairly intelligent, but his intelligence was ill-balanced and his will was
weak. He was also very vain.

He commenced smoking tobacco at the age of fourteen, and he gave
himself so completely up to the habit that at eighteen he was accustomed
to smoke 100 cigarettes a day.

He did not choose to follow the public course of lectures, but
preferred studying at home for his licentiate. He worked hard, but
his labour was so vacillating and so badly directed that he failed to pass
the examination. He was a great reader, but his reading was desultory.
He appears to have found more pleasure in the study of chemistry than
in any other branch of knowledge. The description of the effects of
certain alkaloids on man and animals fascinated him. He read many
books on pharmacology and toxicology. He obtained specimens of
various drugs, such as chloroform, chloral, Indian hemp, opium, morphia,
atropia, cocaine, etc., with which he experimented on himself. He made
the first injection of cocaine in August, 1914, when he was eighteen
years and six months old. It appears, therefore, that he became a
toxicomaniac from curiosity. But it is to be noted that in his own
confession he speaks of having been induced to smoke opium by a
friend who had frequented the opium dens of Marseilles and Paris.

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When the war broke out he enrolled himself in a regimental course
•for officer students at Turin. Here he continued the use of cocaine
and morphia. Having completed the course from which he came out
as sub-lieutenant in July, 1915, he was appointed instructor to a squad
of officer students. Although he was saturated with poison, the sudden
change in his life, pride in his appointment and consciousness of
responsibility made him spontaneously and with little suffering give up
the injections. He appears to have almost succeeded in breaking off
the habit.

He passed in due time to the Front, fought bravely, and was wounded
on September 28th, 1915. He was sent to the hospital at Pavia. Here
he took up his old habits, and continued them when he was sent home
■on leave. He now used morphia and cocaine together. He injected
the morphia first, left the needle in the skin, filled the syringe with the
solution of cocaine, and completed the operation. He used large doses
of both drugs. The injections were made in the afternoon, evening
and night, never in the morning. No one except a doctor at Pavia,
who spoke strongly to him on the subject, appears to have suspected
the habit.

After his convalescent leave was ended he passed to the depot as
instructor until the end of May. During the last month, becoming
acting captain, pride again induced him to give up his vicious habit.
Being sent to the Trentino, he fought bravely. For a whole month he
left off the use of the alkaloids, only masticating a quantity of leaves of
Bolivian coca. His regiment being sent to rest at Vicenza, he resumed
his evil habits, using large quantities of morphia and cocaine.

In August his regiment was sent to the Carso. He was now
beginning to show signs of mental and bodily enfeeblement. Finally
he ran short of morphia, which he had been using in large doses, and
when the regiment went into action on November 1st he had been
forty-eight hours without an injection. He advanced bravely to the
attack, but the morphia hunger overcame his physical and moral
strength. He deserted his post, and after wandering aimlessly for three
days he found his way, ill and broken down, to the hospital of his
army corps.

Prof. Bianchini draws attention to the following points:

(1) The age of the patient is exceptional. He was jet. 18. It is
rare to meet with a toxicomaniac under twenty-five.

(2) With classical toxicomaniacs the need of the poison, even from
the beginning, is constant, continued, and progressively increasing.
In this case the need was sporadic, discontinued and non-progressive.
In the case of a classical toxicomaniac voluntary suspension of the use
of the drug is almost impossible ; in this case it was effected spon¬
taneously under certain circumstances and with comparatively little
suffering.

(3) In this case the injections were made in the afternoon, evening
or night, never in the morning. The morphia maniac, on the other
hand, deprived of the poison for some hours and exhausted from want
of sleep, must make the injections in the morning to refresh himself as
an alcoholic drinks to stop his morning tremors. And it is necessary
•for him, like the alcoholic, to continue the use of the drug all through

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the day without measure or method, until in the evening he desists
because his organism is saturated.

(4) The large doses employed by the patient.

(5) The use of morphia and cocaine together. The morphia maniac
rarely uses the two drugs because he is aware of their antagonism. If
he uses the second it is because he is in want of the first or is in search
of new sensations. He is always a monotoxico-maniac. He may
casually employ other poisons, but he finishes by giving preference
to one, of which he becomes the absolute slave.

J. Barfield Adams.

The Influence of Alcohol in the Production of Hallucinations in General
Paralysis of the Insane. (Joum. Nerv. and Ment. Dis., April,
1919.) Immermann , L.

The frequency of hallucinations in general paralysis has been much
disputed, some authors stating they are common, others rare. Immer-
mann’s study was undertaken to determine, if possible, what relation
alcoholism has to hallucinations in paresis. Several theories have been
advanced to account for the occurrence of hallucinations in paretics :
(1) The anatomical theory. (2) The theory of the previous personality
of the patient. This supposes that a paretic who is not merely demented
is suffering from a psychosis in addition to his paresis. (3) The toxic
theory. (4) The psychogenic theory. This possible source has not
been investigated in this study.

Innermann in his 73 cases found 21 patients to be hallucinated—
11 visual, 10 auditory—and 52 patients to be non-hallucinated. He
divides these groups into sub-groups and gives a table showing the
percentages to alcoholism in each sub-group. His conclusions are
summed up as follows: “ (1) In a study of seventy-three paretics the
patients were found to fall into several clinical groups, which tended
to remain fairly distinct. (2) Hallucinations were found to occur in
certain of these groups and tended to remain confined to these groups.
(3) Excessive alcoholism occurred in only some of the hallucinatory
groups, and was at most an indirect factor in the production of the
hallucinations. (4) Certain manic types showed hallucinations and a
high incidence of excess of alcoholic use, abnormal make-up and absent
knee-jerks, but other hallucinatory patients did not show this com¬
bination.” C. W. Forsyth.

Simulation (Malingering ) not an Adequate Diagnosis, {fount. Nero,
and Ment. Dis., September , 1919.) White , W. A.

The writer would confine the conception of simulation (malingering)
to cases where the symptom can be shown to have its origin in the
field of clear conscious awareness of the individual, who at the same
time has the conscious purpose in mind to deceive, to avoid responsi¬
bility or to escape punishment. The diagnosis of malingering is not
an adequate one as we have no right to diagnose from a single symptom.
Experienced psychiatrists look upon simulation per se as a relatively
unusual phenomenon, and see in the simulator an individual with bad
personality make-up and in the symptom an expression of such defect;

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it is the individual’s reaction—his way of meeting a problem presented
to him by reality. His reaction is an indication of a defective per¬
sonality.

The usual attitude of the herd towards the malingerer is one of
condemnation: he deserves punishment. Punishment is useful for
the purpose of reinforcing the repression and is to that extent valuable,
but for the individual the punishment should have nothing of hate
in it. It should be devised with the sole idea of changing the type
of reaction from an antisocial form to a socially acceptable one—that is,
an attempt ought to be made to sublimate the instinctive antisocial
expression. This is only possible by the sympathetic understanding
of the conflict and of the reaction of each individual.

C. W. Forsyth.

An Acute Prison Neurosis of the Anxiety Type, (fount. Nerv. and
Ment. Dis., October , 1919.) Yawger, N. S.

Gleuck has well shown that the criminal occasionally develops a
psychosis as the result of his confinement in prison on the top of a
psychopathic personality. The writer has, however, found that occa¬
sionally an anxiety neurosis is manifested. About one-third of the
convicts coming up for pardon or parole show nervousness to a greater
or less extent—the criminals refer to it as “ pardonitis ” or “parolitis”;
the ones who escape the disorder appear to be those who expect
favourable conditions to await them on their discharge. An account
of the symptoms is given; they do not differ from those found in
anxiety neurosis in life outside the prisons.

Yawger considers that the condition is the result of important
factors aside from the sexual sphere. Some prisoners fear that they
may not be released; a few know that detainers will be lodged against
them and that they will be rearrested on discharge; in others—the
majority—the anxiety neurosis is determined by the thought that when
released they may be homeless and that they will be unwelcome
members of society. C. W. Forsyth.

4. Treatment of Insanity.

The Problems of Pulmonary Tuberculosis in a Psychiatric Hospital,
(fount. Nerv. and Ment. Dis., January , 1919.) Silk , S. A.

This paper emphasises the importance of the tubercular problem in
mental hospitals. Patients will be admitted suffering from this disease
and other patients will develop it later. The duty of every hospital
will be to cure as many cases as possible and to prevent the spread of
the disease amongst non-tubercular patients. As regards general con¬
ditions, the construction of the hospital should be carried out on up-
to-date hygienic lines, allowance being made for the maximum available
amount of sunshine, light and fresh air at all times. Large porches
or enclosed parts should be used for ambulant patients, the ventilation
of wards and dormitories should be thorough, and in winter extra
blankets should be used instead of keeping out fresh air by closing
windows. The food supplied should be wholesome and varied.

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To reduce the occurrence of tuberculosis and arrest the disease a
systematic procedure is necessary. Specially constructed tuberculosis
cottages accommodating 3 per cent, of the population are required, and
in addition a large ward (the “preventorium ”) surrounded by porches
for suspicious cases who do not cough or expectorate. As soon as a
case is diagnosed as suffering from active tuberculosis it should be
transferred to the tuberculosis cottage, but if the disease becomes
arrested it should be transferred back to the “ preventorium ” first, and
later sent back to the general ward or to the tuberculosis cottage as
conditions direct. The routine followed in the tuberculosis department
consists in giving patients additional food, as milk and eggs, at fixed
times between meals, and in rest or the avoidance of strenuous work.
A thorough examination of patients in the “ preventorium ” should take
place at least once monthly, weighing weekly, and the pulse, respiration
and temperature charted twice daily and cough and expectoration
noted. The management of the tuberculosis department should be
under a specially-trained physician, or if impracticable, it should be
entrusted to a member of the staff who is best fitted for the work.
The staff nurses in this department should not be transferred to
ordinary wards. The co-operation of physicians in charge of general
wards is necessary, as they are in contact with the cases in the earliest
stages of the disease, when removal to the tuberculosis department can
be a help both as regards cure and the prevention of the spread of the
disease. Special attention should be paid to dementia praecox cases as
they are very vulnerable to tuberculosis. In order that an early diag¬
nosis of tuberculosis may be made the following rules should be
observed:

(1) A thorough initial physical examination; (2) the weight of every
patient noted on admission and at regular intervals thereafter; (3)
persistent cough or expectoration should be reported to the physician;
(4) a full history should be elicited if possible; (5) all cases showing
symptoms of tuberculosis should be carefully examined.

F. E. Stokes.

5. Pathology of Insanity.

The Correlation between Mental Defects and Anomalies of the Hard
Palate. ( Amer. Journ. of Insanity, April, 1919.) Case, Irene.

This investigation was carried out in the Psychopathic Laboratory of
the University of Chicago, on the casts of the palate of forty-six normal
and abnormal children brought to the laboratory, and is an attempt to
test the doctrine, taught for over three centuries, that a deformed
palate is frequently found in the feeble-minded. Is it really true, the
author inquires, that a defective palate indicates a defective mentality ?

The cases seem too few for assured results, but the examination was
elaborate, and the measurements of the palate were considered in
relation to the measurements of the head and to the “ mental age ” of
the subject. The author’s main contention is that the size of the
palate is correlated with the size and shape of the head. The abnormal
palate varies more than the normal simply because the head varies

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more in size and shape in abnormal than in normal individuals. In
general two types of palate were noted : (1) High and narrow, associated
with a dolichocephalic head; (2) low and broad, associated with a
brachycephalic head. Thus the head form determines the palate form,
and either of the two forms may be normal. There is no necessary
connection between a low mental capacity and a high palate. The
female palate is smaller than the male, except as regards height ; this
depends on a general tendency for small heads to have high palates.
As for asymmetry, the normal individuals showed it as generally as the
abnormal and sometimes to as marked a degree.

Havelock Ellis.

Notes on the Relation of Tuberculosis to Dementia Prcecox. (Journ.

Nerv. anti Ment. Dis., September , 1918.) Southard, E. E., and

Cameron, M. M.

The statistics used for this study were obtained from the autopsy
series of the Massachusetts Institution for the Insane. Of 5,040
autopsies there were 403 cases of dementia pnecox, of whom 301 died
of proved and 15 of doubtful tuberculosis, and 339 cases of manic-
depressive psychosis, of whom 224 died of proved and 20 of
doubtful tuberculosis. There were 87 cases of dementia pnecox
and 95 cases of manic-depressive psychosis who showed no signs of
tuberculosis postmortem. In this group of dementia prascox cases the
tuberculosis hypothesis could not be raised as to aetiology on any
anatomical grounds. It is possible that these non-tubercular cases
were incorrectly diagnosed ? To test this hypothesis the symptomatology
of non-selected cases from the Danvers collection was examined.
These cases of dementia prtecox were divided into two groups: (1)
Tubercular, (2) non-tubercular—proved so post-mortem —there being
36 of the former and 27 of the latter. The tubercular as compared
with the non-tubercular cases were equally subject to dementia and
to delusions of persecution, were more apt to be resistive, violent, and
subject to psychomotor excitement, were more suicidal, manneristic,
disorientated and confused, and slightly more subject to delusions
involving personality; the non-tubercular cases were more apt to be
peripherally restless, mute, refuse food, and be subject to somatic
delusions. Can it be that tuberculosis supervening in dementia prsecox
directs the symptoms more towards catatonia and to hyperkinetic
symptoms presumably of a psychogenetic or central nature, and less
to peripheral forms of hyperkinesis, and may tuberculosis cause a
trend of symptoms towards the manic-depressive psychosis ?

F. E. Stokes.

6 . Sociology.

Psychiatry as an Aid to Industrial Epficienty. ( Amer. Journ. of
Insanity, April, 1919.) Bell,fu Don.

The psychiatrist who realises the changed conditions of the times and
the urgency which labour and economic conditions are to-day assuming
may sometimes ask himself where he comes in. Dr. Bell attempts to

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help him in answering this question, basing his conclusions on the
results of visits to large industrial plants in various parts of America,
interviews with managers and men, and much detailed study of indi¬
vidual workmen. He believes in close relationship between employer
and employee and the stabilisation of industry by practical scientific
selection of human material, creating trust, confidence and co-operation.
To this end it is necessary to study the individual as to his physical,
nervous and mental fitness for his job, and to ascertain his special
abilities and disabilities. Prophylactic measures adopted now, with
the sympathetic co-operation of labour and industrial leaders, will
prevent the disease of inefficiency from making further inroads upon
either capital or labour, stabilising and unifying both. The present
industrial research—not only scientific in aim, but practically humane
and economic—is the preliminary stage of a work which, the author
believes, has not previously been attempted.

The chief part of this paper deals with methods of procedure and
schedules. The methods include (i) general medical, (2) neurological,
(3) psychiatrical, (4) psychological, and (5) social, since the scheme
involves the co-ordination of all scientific aids in industrial examina¬
tions. Such a scheme could be put into operation in the employment
bureau of industrial organisation, and also used to ascertain the
physical, nervous and mental equipment of workers already employed.

As an example, the results of an examination of fifty-seven employees
of an industrial company is presented shortly before a strike occurred.
All the strikers were found to have something wrong with them from a
nervous or mental standpoint, nearly all having a psychopathic history.
Such an examination, it is claimed, is of value in predetermining
conduct and enabling the employer to remedy conditions likely to
cause trouble.

The author concludes that it is desirable, even from an economic
point of view, to establish medico-psychological laboratories as the
principal department of employment bureaus of every large industrial
organisation, and further advocates the establishment of a central
employment clearing-house with medico-psychological laboratory to
act for groups of industrial organisations too small to economically
conduct their own bureaus. There should be a representation of
labour in all such bureaus, which would react to the benefit alike of the
individual, the industrial organisation, the labour organisation and the
community. Havelock Ellis.

7. Mental Hospital Reports, 1918-19.

Report on Lebanon Hospital , 1918-19.

The Twentieth Report, covering 1918-19, is an extraordinarily inter¬
esting one, and it gives a clear account of the good work done at this
international asylum. It also points out the great amount of tact that
was exhibited by Dr. Watson Smith. In fact, it is almost like a romance
to find that, of all institutions, hospitals and the like that had been
under the control of Europeans, it was the only one that was not seized
upon by the Turks and altogether upset. On several occasions there

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were missions from Turks with the idea of taking over the place and
of replacing the doctor there, but by the exercise of an extraordinary
amount of tact he was able to get the Turks to recognise that it was not
an English institution, but was a benevolent institution, by which the
Turks gained as much as did Europeans. So that, even when thousands
were dying in the neighbourhood of starvation, the hospital was able to
get a steady supply of flour. There was a time when the assistance of
the United States was very useful to the institution.

For two years during the war Dr. Watson Smith practically never left
the building : it was not safe for him to do so, as he might easily have
been deported. Fortunately, since then he has been able to leave his
work and get a rest, the while he is acting as propagandist in Europe
and America. And we trust that when he returns to his arduous task
he will be encouraged by the support that he has gained in these two
countries.

Not only was the asylum used for the ordinary patients, but the
Turks themselves removed a considerable number of patients who were
certainly in a very distressed and distressful condition from Damascus:
and later on it was utilised for the soldiers of the Allied forces.

During the war Dr. Watson Smith had very great difficulties to con¬
tend with, such as difficulties with the authorities in getting food. And,
without going into details, I may say that, one way and another, he
managed to surmount them all and was able to keep on good terms
with the Turkish authorities, so they gave him much less trouble than
was given to the administrations of other foreign institutions. It is
quite certain that admirable work is being done, and that all praise is
due to Dr. Watson Smith. There is no doubt that, as in Egypt, there
is a very great want of further development and further accommodation,
and as this Lebanon Hospital is international and receives considerable
support not only from England and America but also from other
countries, such as Switzerland, one feels confident that a great future is
before it. George H. Savage.

Lunacy in Egypt , 1918.

Once more we have to note the receipt of the annual report of Drs.
Warnock and Dudgeon, and once more we have to speak of it as a
model of what such reports should be. During the year Dr. Warnock
had a much-needed holiday and his place was filled by his deputy, Dr.
Dudgeon.

The chief points only can be extracted from the report for every page
is noteworthy. The usual overcrowding at both asylums occurred, with
the inevitable result that many patients had to be sent away when only
convalescent, and many of these relapsed and many were readmitted as
criminals.

Dr. Warnock points out the need for several more asylums; there
should certainly be one near Alexandria and a special one for the male
criminal lunatics, who, at present, have to be placed in the Cairo asylum
of Abbasiya. Besides these there should be receiving homes, for though
a fair proportion of the cases pass through local hospitals no special
provision is made for them. The usual difficulty about a suitable staff

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was accentuated, for many were called up for military duties. The
medical instruction connected with the Egyptian School of Medicine was
continued.

In addition to the local cases provision had to be made for soldiers
connected with the British Army. This was managed by taking over
the house of the former Assistant Medical Officer.

There was nothing very special about the cases, though it seemed a
large proportion were defectives who ought never to have been enlisted
and certainly not sent abroad. A table is given of the nature of the
cases; very few deaths occurred, but few of the patients were long resident,
being sent out of Egypt as soon as possible. Carefully arranged
tables are given of the patients who were received as criminals and the
various crimes for which they were under treatment, also the supposed
causes of the mental disorder. Here it is noteworthy that pellagra
played a very important part; crimes of violence were common. It
certainly is one of the blots on the Egyptian Government that the
criminals and lunatics are herded together, though, as Dr. Warnock
points out, he separates them as much as possible. A fair proportion
of general paralytics were admitted and quite a large proportion of
these were women. Wassermann reaction proved positive in most but
not in all of the cases. The examination was conducted in the Govern¬
ment Laboratory and is therefore to be trusted. Besides the general
paralytics a large number of other patients were examined and a very
large number, especially of the pellagrous cases, proved positive. This
is noteworthy. The diet was to a considerable extent modified during
the war and a careful study of the dietary was made in relation to the
pellagra.

Prof. Wilson, of the Government Health Department, advised on this
and caused modification of the diet making up for the deficiencies, but
with all the treatment the disease when once establised is believed by
Dr. Dudgeon to be incurable. He tried all sorts of remedies for the
various symptoms, and though remissions did occur the disease returned.

The death-rate was high, but this was partly due to bad diet and
partly to the gradual accumulation of old and chronic cases. Post-
mortems were frequently made and scientific work would have been
carried out if the staff had not been shorthanded.

The tables giving the local incidence of insanity are of only local
interest, but one has to notice that the general paralytics come most
from Cairo and cities while the pellagrous come largely from the
provinces. The details of the cost and the modification in the building
are given.

As to treatment sedatives were not given to any extent and practically
no restraint was used; very few accidents of any kind are recorded.

We must extend our sympathy to the doctors and their families
because the disturbed state of the country has rendered their lives irk¬
some and even dangerous.

Dr. Dudgeon gives a special and interesting account of the work
done at Khanki. He receives chiefly the provincial patients direct but
also a proportion of the chronic cases from Cairo. His asylum is
of course new and growing. It was always more than full and for a
time he had water and other difficulties, but he has done great

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things in converting a desert into an oasis. He provides vegetables
for his own and for the parent institution and makes the farm remune¬
rative. Gradually means of approach to Cairo are improving so that
the asylum is not so isolated as it was. Excellent tables are given and
much information about pellagra and its symptoms are collected; here is,
too, an interesting table as to the result of examination of the faeces of
a large series of cases and a list of the prevalent parasites is given.
Influenza was a source of trouble but was not as fatal as might have
been expected.

We feel that the report should be more generally seen, and we are
sure that the English alienists have reason to be proud of the work of
their Egyptian colleagues. George H. Savage.

Part IV.—Notes and News.

MEDICO-PSYCHOLOGICAL ASSOCIATION OF GREAT BRITAIN

AND IRELAND.

The Ordinary Quarterly Meeting of the Association was held at the
Medical Society’s Rooms, No. n,Chandos Street, W. 1, on Tuesday, February
24th, 1920, Dr. Bedford Pierce (President) in the chair.

Members present: Dr. Bedford Pierce (President), Major R. Worth (General
Secretary), Sir R. Armstrong-Jones, Sir F. W. Mott, Drs. H. Baird, G. F. Barham,

F. Beach, C. W. Bower, D. Bower, A. Helen Boyle, J. Chambers, G. Clarke,
R. H. Cole, P. C. Coombes, H. Corner, M. Craig, A. W. Daniel, J. F. Dixon, R.
Eager, J. H. Earls, H. Eggleston, S. C. Elgee, A. E. Evans, S. J. Gilfillan, H. E.
Haynes, R. D. Hotchkis, D. Hunter, G. H. Johnston, M. H. Johnston, J. Keay,
E. S. Littlejohn, J. R. Lord, J. A. Lowry, W. F. Menzies, J. Middlemass, A. Miller,
D. Nicholson, D. Ogilvy, E. S. Pasmore, N. R. Phillips, D. Ross, G. E. Shuttleworth,
J. H. Skeen, G. W. Smith, R. P. Smith, J. G. Soutar, J. B. Spence, R. H. Steen,
J. Stewart, R. C. Stewart, F. R. P. Taylor, D. G. Thomson, E. Barton White, H.
Wolseley-Lewis.

Members present at the Council Meeting: Drs. Bedford Pierce (President),
R. Worth (General Secretary), D. Bower, A. Helen Boyle, J. Chambers, R. H.
Cole, M. Craig, A. Daniel, R. Eager, R. D. Hotchkis, J. Keay, J. R. Lord,
H. C. MacBryan, T. C. Mackenzie, W. F. Menzies, A. Miller, J. Noel Sergeant,

G. E. Shuttleworth, J. H. Skeen, R. H. Steen, D. G. Thomson and H. Wolseley-
Lewis.

Apologies were received from Profs. Obersteiner (Vienna) and Emil Kraepelin
(Munich), and Drs. L. R. Oswald, G. Douglas McRae, J. P. Westrupp, J. Mills,
D. A. Pilcz (Vienna), J. Whitwell, R. B. Campbell, T. Stewart Adair, G. M.
Robertson and J. N. Greene Nolan.

The minutes of the last meeting, having already been printed and circulated in
the Journal, were taken as read and were duly confirmed.

Matters arising from the Council Meeting.

The President said the next item concerned business which arose out of the
Council meeting just held. He asked Major Worth to refer to the appointment of
a Handbook Committee.

Major Worth (Secretary) said the following members had been approached to
form themselves into a Committee charged with the revision of the Handbook,
under the style “The Editorial Handbook Committee” : Representing England—
Dr. Bedford Pierce, Dr. Middlemass and Dr. Rees Thomas; representing
Scotland—Dr. Mackenzie, Dr. Donald Ross and Dr. George M. Robertson;
representing Ireland—Dr. Rutherford and Dr. Nolan. All these gentlemen had
expressed their willingness, and steps were being taken to call them together.

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The other matter arose from certain correspondence he had had with the
National Asylum Workers' Union. Probably members were aware that that
Union was taking steps to bring before Parliament some amendments of the
Asylum Officers’ Superannuation Act, 1909. He also had been in correspondence
with the Clerks’, Stewards’ and Storekeepers’ Association, on the same subject,
and it had been decided that a conference should be held, consisting of four
members of the Union, two members of the Clerks’, Stewards and Storekeepers’
Association, and two members of our Association. As representatives of our
Association Dr. David Thomson and himself had been chosen, their function
being chiefly to hold a watching brief, because, at the moment, they had no
definite mandate.

The President said there was one other matter which came forward from
the Council meeting. The Asylum Workers’ Association had a small fund for
the benefit of nurses who were sick, the amount of the fund being about £80, and
they had invited this Association to administer that fund when the Asylum
Workers’ Association shall have closed down finally. At that morning’s Council
meeting it was decided to accede to that request. The Secretary and Treasurer,
with Dr. Shuttleworth and Dr. Powell, were appointed to act as a small Committee
to deal with cases as they arose.

Another subject which was discussed by the Council, and which he brought
before the meeting, was one arising out of a letter which had been received
pointing out the serious and grave hardship many old asylum workers were under
owing to the depreciation in the value of money, and it was thought it would be
proper for this Association to draw attention to the matter. It did not require
any speech to justify it. A pension which was no more than modest when granted
was very meagre indeed at present value of a sovereign. With the approval of
this Association, it had been suggested that he, the Secretary and Dr. Miller,
jointly, should write a letter on behalf of this Association, pointing out the serious
hardship accruing to many old asylum servants through the depreciation in the
value of their superannuation allowance, and that this letter be sent to the Prime
Minister, the Minister for Pensions, the Minister of Health, and the Secretary
of the Hospitals’ Association, and such others as were likely to be influenced by
the communication. He asked if any had observations to make.

Sir Robert Armstrong-Jones said he did not think it would be possible to
alter the amount of the pensions, as they had been granted according to law, and
to change it a new law would be required.

Lt.-Col. Lord said that this was understood, and the idea was that a change in
the law should be advocated.

Dr. Dixon said he thought the difficulty was that the same question arose
regarding old pensioners of the army and navy.

The President said that this communication would only refer to the matters of
which we had definite information, although, of course, it raised a much wider issue.

The meeting approved the communication being sent.

Study Facilities for Assistant Medical Officers.

Lieut.-Col. D. Thomson said members would remember that a very valuable
paper was read before the Association at the last meeting on the question of the
special education of junior medical men who took up this specialty. This was a
subject which required to be tackled and dealt with afresh, now that all were more
or less settling down to their former work, and the subject was coming forward
more definitely. He suggested that the committee, which previously dealt with
this and allied subjects in 1908 when it was first brought forward on a short paper
of his own, might be a suitable body to be reconstituted for this purpose. The
chairman on that committee had retired from active work, but he was present to¬
day. He referred to Dr. McDowall. That committee did splendid work, and
issued the report which was well known (vide p. 373, July number, 1910.— Eds.).

The President said he thought a committee should be set up to deal with the
many important aspects of this subject, such as that of study-leave.

Lieut.-Col. D. Thomson said that progress had been made, and there had now
been established a series of courses of lectures at the Maudsley Hospital. Many
junior medical officers throughout the country were eager about this matter, and
he thought this Association ought not to drop the subject after doing very good

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pioneer work. He moved that a committee of this Association be appointed to
consider the very important questions which now arose in connection with the
obtaining of the diploma in psychiatry.

The President said he would like to hear Dr. McDowall speak on the subject,
and perhaps he would second Dr. Thomson's proposition.

Dr. McDowall seconded the motion of Lieut.-Col. Thomson.

Lieut.-Col. Lord said he hoped it would be an instruction to the committee to
go into the whole question of medical officers’ duties. The great dearth of medical
officers, and the difficulty of getting junior men from the hospitals to select
psychiatry as their life-work, was that the work was not made sufficiently attractive
quite apart from questions of pay and conditions of service generally. The
problem of the cure of insanity was the most difficult one in the whole region of
medicine, and therefore the very best brains in the profession should be attracted
and brought to bear upon it or progress would be impossible. A sound training
in scientific psychiatry was the first step, then opportunities for further study from
time to time, and the routine work to be essentially professional and not admini¬
strative, the latter being adapted to secure this.

Sir Frederick Mott said that it would be wise to include a young and junior
medical officer among those who would form the committee.

Dr. Passmore said he would like to suggest that this committee consider the
subject of quarters for married assistant medical officers. The absence of such
accommodation was a drawback in the case of those who might wish to enter
the specialty.

The President said he gathered that the burden of Col. Thomson’s motion was
the scientific training of the younger men in the specialty, the best method of
securing and encouraging effective training, to assist them in obtaining a diploma
in psychiatry, and generally promote the scientific side of the work. To intro¬
duce the other matters would complicate the reference.

Dr. Bower said one of the chief subjects Col. Thomson was interested in was
the difficulty which assistant medical officers laboured under in getting away from
their duties on study-leave. That was a matter on which there was a need of
strong recommendations by the Association, and he thought that generally com¬
mittees of asylums would need to be educated on the matter and would fall in with
any good scheme which the Association might approve.

The President replied that the first step was to appoint the committee; its con¬
stitution would come later.

The appointment of a committee was approved.

Col. Thomson said that such members of the former committee as did the spade¬
work on this subject should be re-appointed; it would be invidious for him to
mention names. He thought Col. Lord should be on it: he was in London, and
in touch with London mental hospital work. If the meeting would agree to
the appointment of the original committee, with power to add to their number,
that would save the nomination of individual members. The reference, he thought,
should be that the committee consider the whole subject. Diplomas in psychiatry
had already been established at five Universities. He had spoken on the matter to
one or two active, ambitious young men associated with him at Thorpe, Norwich,
and they said—“ Yes, it is very nice, but how can we get study-leave ” ? The
Maudsley Hospital courses were convenient for London men, but what about the
provinces ? He thought the Association should consider how the young men
joining the specialty, or those whom it was hoped would be induced to join it, best
could take advantage of the existing provisions. Details as to the provision of
married quarters concerned individual asylum committees.

The President suggested “ To consider the best method and facilities for
training in psychiatry, and for the obtaining of the diplomas which exist,” should
be the reference for the committee.

Col. Thomson agreed.

After further discussion by Dr. Soutar and Dr. Bowers—

The President suggested as members of the committee Col. Thomson, Col.
Lord, Dr. T. W. McDowall, Sir Frederick Mott and Col. Rows, with power to add
to their number.

Sir Frederick Mott repeated his former suggestion.

Dr. Nicholson said Dr. Soutar would be an excellent member of this committee.

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Col. Thomson suggested that perhaps Dr. Bond would be willing to serve.

The President said Dr. Chambers was willing to serve ; he hoped Dr. Bond
also would consent to do so.

Sir R. Armstrong-Jones suggested Dr. Helen Boyle.

This concluded the list.

The following were elected members of the Association :

Parnis, Henry William, M.R.C.S., L.R.C.P., A.M.O., London County
Mental Hospital, Colney Hatch, N. 11.

Proposed by Drs. Gilfillan, MacArthur and Worth.

Haynes, Horace Guy Lankester, M.R.C.S., L.R.C.P., Littleton Hall,
Brentwood, Essex.

Proposed by Drs. Sergeant, Haynes and Bower.

Shearer, Christina Hamilton, M.B., Ch.B., Visiting Physician, Lady
Chichester Hospital, 11, The Drive, Hove, Sussex.

Proposed by Sir Robert Armstrong-Jones and Drs. Helen Boyle and Percy
Smith.

Robinson, William, M.B., Ch.B., D.P.M.Leeds, Senior Assistant, Wakefield
Asylum, West Riding Asylum, Wakefield, Yorks.

Proposed by Drs. Shaw Bolton, W. Vincent and T. Stewart Adair.

Parkin, George Gray, M.B., Ch.B., Assistant Medical Officer, Cheshire
County Asylum, Parkside, Macclesfield.

Proposed by Drs. Parkin, Dove Cormac and Stewart Adair.

Heal, James Gordon Freeman, L.M.S., N. Scotia Provin. Med. Bd., 1915,
M.D., C.M., 1915, Swallows’ Nest, Felixstowe.

Proposed by Drs. Gilfillan, MacArthur and Worth.

Paper.

Dr. R. Hunter Steen : “ Chronic Hallucinatory Psychosis ’’ (vide p. 99).

The President said he thought members could congratulate themselves, also
Dr. Steen, on an exceedingly able paper, and particularly on the charming and
lucid way in which he had presented the subject. Rarely did the Society hear a
contribution which was so easy to listen to because so clearly expressed. It went
a long way towards making a successful meeting to have a subject presented in a
forcible and clear way. Dr. Steen had endeavoured in this paper to show his
colleagues a new psychosis, to make out a case for a fresh clinical entity. The
train of symptoms was one with which all psychiatrists were familiar; there was
no one in the room who had not seen patients of the type Dr. Steen had just
described, and it was to be hoped there would be a good discussion. In reference
to the definition of paranoia, and whether such cases had hallucinations as a
marked symptom, he said that some of those present would remember Dr. Percy
Smith's Presidential Address on that subject, in which he showed that the definition
of paranoia was far from lucid and exact, and that what passed under that name
was hardly a definite clinical entity. He (Dr. Pierce) could not agree with Dr.
Steen, for he believed cases of paranoia had hallucinations, and for that reason he
was inclined to think Dr. Steen had not fully separated his malady from paranoia.

Dr. Menzies said he had never seen a case of paranoia without hallucina¬
tions of hearing, and, with all respect to Kraepelin and his school, he did not
think such existed. He did not know whether Dr. Steen had followed up
cases of the kind for twenty or twenty-five years, but they certainly become
very demented, and in the end ordinary chronic lunatics. On making a post¬
mortem examination on such one always found the usual thickening and cortical
wasting. They could not be distinguished from other chronic mental cases. It
might be that the alienist did not see the cases described by Dr. Steen, as they
did not progress, and hence did not find their way into asylums, but the kind which
did go there progressed steadily. They were called paranoics at first, and after¬
wards were known as chronic maniacs. It came once more back to the question
of all forms of insanity being but one. Everything in insanity known at present
was, more or less, only a symptom, as Clouston tried to point out many years ago.
Still, giving a name to a condition helped, and when it was discussed it could be
with a knowledge of what was meant. With regard to the anatomical point of
view he had his quarterly debate with Dr. Bolton, and he (Dr. Menzies) always
suggested that the reason why the cerebral hemispheres became so wasted and

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membranes thickened in that area was partly geographical, partly developmental;
that the spinal fluid secreted by the choroid plexuses under pathological circum¬
stances was toxic, and it was possible that might affect directly the pyramidal
cell layer of the audito-sensory and audito-psychical centres. He did not see,
however, why research into these conditions need be confined to the psychical side.
Unless the attack were conducted from the anatomical, and especially from the
chemical standpoints, there was not likely to be much progress, because, after all,
psychology only indicated certain steps on the way.

Dr. Percy Smith said the President had been good enough to refer to his (the
speaker’s) Presidential Address on paranoia. As, however, that was now some
sixteen years ago, he was entitled to have forgotten what he then wrote. He
believed he then pointed out that people who had described paranoia—many in
Germany and other countries had written on it—had referred to acute hallucinatory
paranoia and chronic hallucinatory paranoia. Included in paranoia there was
mentioned^ by different authors, almost every kind of acute psychosis met with,
even acute delirious conditions, which was absurd. He did not think he said in
his address that in no cases of paranoia were there hallucinations; any assertions
of that kind he would regard as far too sweeping. It had been the fashion of late
years to say that if a patient had hallucinations it was not a case of paranoia,
which seemed to him to be on a par with saying that in cases of paranoia there
was no emotional disturbance—a statement which was at one time current. He
believed one of the points he made in his paper referred to was to show that
cases, to which the term “paranoia” was properly applied, began often with
serious emotional disturbance. His view was that many cases of paranoia did have
hallucinations. He was not present to hear the first part of Dr. Steen's paper,
therefore he did not know what the author said about the aetiology of the condi¬
tion he described; but no doubt psycho-analytical friends would say, " Are not
these cases psychogenetic ? ” Many of the cases sounded like those in which
there was a history of exhaustion, or of a toxic condition, like that resulting from
alcohol.

The President said that before calling upon Dr. Steen to reply he would like
to ask him whether he was prepared with any suggestion as to how it was possible
for a mental conflict to produce mental dissociation. He was sorry there had not
been a fuller discussion, but probably that was because it was a subject which
members would like to think over at leisure before expressing any decided opinions.

Dr. Steen, in reply, said he was very grateful for the way in which members
had listened to his paper. In regard to the question asked by the President as
to why a conflict produced dissociation, he was sorry he was unable to give a
satisfactory answer. Still, he had no doubt that a mental conflict did produce
dissociation, especially if such conflict had been rigorously repressed ; he laid stress
upon this last point. In the first case he related there was a very severe mental
conflict, which was being sternly repressed. After this had been revealed to the
patient the symptom ceased. Unfortunately he had not then time to proceed
further with the investigation; it was during the war, and his time was very fully
occupied. Therefore he did not carry out a full psycho-analysis. The symptoms
disappeared for three years, though unhappily at the end of that time the patient
returned, with the symptoms even intensified owing to the return of the conflict.
The discussion on the paper had ranged largely round the question of the similarity
of the condition he had described to paranoia. Dr. Percy Smith had said there were
hallucinations in paranoia; and he (Dr. Steen) would agree there were hallucina¬
tions in some cases of paranoia, but he wished specially to point out that paranoia
was a disease characterised by delusions, and the rule was for hallucinations
to be absent; the latter were not a characteristic feature of paranoia. On the
other hand, the cases he had described were so characterised. In the first of the
cases, for instance, a girl came to him with weeping fits, and he then discovered
she heard voices. After talking to her on three or four occasions the voices
ceased. There were no delusions. Her case was not one of paranoia as he
understood it. The second case had had hallucinations of hearing for about six
years, but there were no delusions whatever. He could not fit that case into
paranoia either. Eventually she might develop delusions—indeed, he thought
that process had already commenced. He could not call that case one of
paranoia. He had been glad to hear what Dr. Menzies said about a physical

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basis for hallucinations. In his own reading on the subject of hallucina¬
tions and their study the conception of them from a physical standpoint had
not helped him in the least. Approach from the psychical side did, however, give
him a better insight into the condition. A physical basis must exist, but if
these hallucinatory cases were viewed from the standpoint of the existence of a
mental conflict in the patient, which was being repressed, and efforts were made
to deal with this in an early stage by psycho-analysis, he believed many of them
would recover.

SCOTTISH DIVISION.

A Special Meeting of the Scottish Division of the Medico-Psychological
Association was held in the Royal College of Physicians, Queen Street, Edinburgh,
on Friday, February 13th, 1920.

Present: Lieut.-Col. Keay, Major Hotchkis, Drs. Buchanan, Drummond, Kerr,
MacDonald, Tuach Mackenzie, Oswald, G. M. Robertson, Skeen, Shaw, Steele,
and R. B. Campbell (Divisional Secretary).

Lieut.-Col. Keay occupied the chair.

Apologies for absence were intimated from Drs. Easterbrook, McRae, Carre,
T. C. Mackenzie, Donald Ross, and Crichlow.

The Secretary read a letter which he had received from the Secretary of the
Scottish Board of Health, requesting the Scottish Division of the Medico-
Psychological Association to submit the names of two "suitable persons” to the
Board of Health for their consideration in appointing a General Nursing Council
in terms of the Nurses’ Registration (Scotland) Act, 1919. The Secretary stated
that he had referred the matter to the Business Committee, who had nominated
Drs. G. M. Robertson and L. R. Oswald, and that he had sent their names to the
Scottish Board of Health. The Division approved of the Business Committee's
selection, and also the action taken by the Secretary.

The Nurses’ Registration (Scotland) Act was then considered in detail and
various points discussed. It was decided that the Business Committee should be
authorised to act as an Advisory Committee to the Division’s representatives on
the General Nursing Council, to whom all matters could be referred.

The Division considered it would be expedient to have someone representing
mental nurses nominated as a member of the Nursing Council. In the course of
discussion it was pointed out that the Board of Health had already taken steps to
have this done. It was finally decided that the Secretary should find out if this
was the case, and if on inquiry it was found that no nomination had been made,
Lieut.-Col. Keay and the Divisional Secretary should interview the Board of
Health, and lay stress on the advisability of having someone nominated to
represent the interests of mental nurses.

A vote of thanks to the Chairman for presiding terminated the business of the
meeting.

A Meeting of the Scottish Division of the Medico-Psychological Association
was held in the Hall of the Royal Faculty of Physicians and Surgeons, Glasgow,
on Friday, March 19th, 1920.

Present: Lieut.-Col. Keay, Drs. Buchanan, Clarkson, Chislett, Easterbrook,
Kate Fraser, Hotchkis, Henderson, Kerr, Macdonald, McRae, Richards, Roberts,
and R. B. Campbell (Divisional Secretary).

Lieut.-Col. Keay occupied the chair.

The Minutes of last divisional meeting were read and approved, and the
Chairman was authorised to sign them.

The Secretary intimated apologies for absence from Drs. G. M. Robertson,
Oswald, Orr, Tuach Mackenzie, Shaw, T. C. Mackenzie, Skeen, Steele, Ross, and
Boyle.

The Secretary read the following letter which he had received from the
Secretary, General Board of Control, regarding the petition which had been sent
to the Board in support of the continued employment of female nurses in the male
wards of asylums:

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[Copy.]

General Board of Control for Scotland,
Edinburgh ;

March 8th, 1920.

Sir, —Your letter enclosing a memorial from the medical officers of Scottish
asylums on the question of the attitude of the Asylum Workers' Union towards the
employment of female nurses in the male wards of asylums was laid before a
meeting of the Board held here on the 3rd inst.

In reply I am directed to state that in the opinion of the Board it is highly
regrettable that an economic dispute, unconnected with the intrinsic merits of the
important question at issue, should imperil a system of nursing which affects the
comfort and happiness of thousands of helpless individuals.

The Board have always regarded the introduction into asylums of the nursing
of male patients by women as among the more important advances in the care of
the insane which has occurred in the history of Scottish lunacy administration.
The Medical Commissioners early recognised its value, and they have constantly
advocated its extension because of its beneficial results and its humanising
influence, not only upon the patients immediately subjected to it, but upon the
general tone of the institutions in which it has been adopted.

For many years in this country the sick of both sexes and of all classes, whether
in hospitals or in private houses, have been tended by female nurses, and the Board
can conceive of no valid reason why the male inmates of asylums, with very few
exceptions, should not equally participate in the same benefit.

The medical officers of Scottish asylums may rest assured that the Board will
continue to use their influence in the direction of supporting and extending the
nursing of the male insane by women.

In view of the importance they attach to the matter, the Board have directed
that a copy of the memorial and of this letter be sent to the Secretary for Scotland
for his information.

I am, Sir,

Dr. Campbell, Your obedient servant,

Stirling District Asylum, A. D. Wood,

Larbert. Secretary.

The Division were gratified to learn of the warm support offered by the General
Board, and unanimously agreed that the letter should be incorporated in the
Minutes. The Secretary was instructed to write the General Board of Control
expressing the thanks of the Division for the letter and for their promise to
support, and at the same time to ask permission to circulate copies of the letter
to the asylum authorities who received the petition, namely, clerks of District
Boards of Control and secretaries of Royal Asylums Boards.

The Secretary submitted a letter which he had received from Dr. John
Macpherson, Senior Commissioner, General Board of Control, proposing that
arrangements might be made during this summer, preferably a date in either the
month of May or June, to visit one of the “boarding-out" colonies to have a
demonstration of the Scottish system of “ boarding out.” The Division approved
of the proposal, and the Secretary was asked to write Dr. Macpherson thanking
him for his offer. The Secretary was requested to make the necessary arrange¬
ments for the proposed visit.

Drs. T. C. Mackenzie and G. Douglas McRae were unanimously elected
Representative Members of Council for the ensuing year, and Dr. R. B. Campbell
was elected Divisional Secretary.

Dr. D. K. Henderson read an interesting and instructive paper on “Anxiety
States occurring at the Involutional Period,” which was followed by a discussion
in which several members took part.

A vote of thanks to the Chairman for presiding terminated the business of the
meeting.

LXVI.

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IRISH DIVISION.

Special Meeting: Memorandum to the Chief Secretary.

It having come to the knowledge of the Irish Division that the Ministry of
Health " Irish Public Health Council,” recently appointed, were at present dealing
with matters possibly vitally affecting the interests of the insane poor and the
future welfare of the Irish Asylum Service, it was decided to hold a special and
urgent meeting of the Irish Division, so that a memorandum embodying the views
of the members be placed, as soon as possible, before the Public Health Council,
who had notified their willingness to receive a deputation from the Irish Division
of the Medico-Psychological Association.

The meeting was held on February 14th, at the Royal College of Physicians,
Kildare Street, Dublin.

Members present: John M. Colles, LL.D., K.C. (in the chair), Lieut.-Col. W. R.
Dawson, Drs. M. J. Nolan, J. O'C. Donelan, Greene, H. Eustace, Irwin, H. R. C.
Rutherford, O’Donerty, John Mills, Rainsford, Gavin, Benson, Leeper (Hon. Sec.).

The Hon. Secretary stated to the meeting that the Parliamentary Sub-Com¬
mittee of the Irish Division were directed at the autumn meeting to prepare a
memorandum in connection with the proposed Public Health Council set up
by the Minstry of Health, and present same to the spring meeting of the Irish
Division. At the time it was not at all clear that this newly-appointed body
intended to deal with the Asylum Service and matters in connection with the
treatment of the insane. It having come to our knowledge that the Public Health
Council was, however, now actively engaged in dealing with these matters, the
Parliamentary Sub-Committee had drawn up a memorandum which they begged
to lay before the members for consideration. It seemed to be of the utmost
importance that the considered views of the members of the Irish Division should
be laid before the Public Health Council before that body attempted to recommend
legislation, especially as the Asylum Service had no representative whatsoever
upon the Health Council, and had apparently been deliberately denied representa¬
tion upon it.

Dr. Nolan had kindly drafted a memorandum which was submitted to the
meeting and discussed clause by clause and finally adopted as amended by the
meeting, and it was decided to accept the invitation of the Public Health Council
and send a deputation to lay the important matters dealt with in the memorandum
before them.

It was proposed by Dr. Mills, Ballinasloe, seconded by Dr. H. Eustace, and
passed unanimously, " That the following be asked to form a deputation and wait
on the Public Health Council: Dr. M. J. Nolan, Downpatrick; Dr. J. O’C.
Donelan, Richmond Asylum; Dr. Greene, Carlow; Dr. Martin, Letterkenny;
Dr. O’Doherty, A.M.O., Omagh District Asylum ; Dr. Rainsford, Stewart Asylum ;
Dr. Gavin, Mullingar Asylum; Dr. Leeper to act as Hon. Secretary.”

Dr. O’Doherty wished a clause inserted dealing with the compulsory retire¬
ment of medical superintendents at an age limit. This was fully discussed, but
not generally approved by the meeting.

Memorandum of the Irish Division of the Medico-Psychological
Association of Great Britain and Ireland relative to Lunacy
Administration in Ireland and other matters affecting the Improve¬
ment and Increased Efficiency of the Irish Asylum Service.

In connection with the proposed establishment of a Ministry of Health for
Ireland, the Irish Division of the Medico-Psychological Association directs
attention to the special needs of the Asylum Service in Ireland.

The care and treatment of the insane, as a branch of Public Health service,
cannot properly fall within the ordinary scope of local government administration.
The proportion of the population of Ireland concerned in this service is very
large, the personnel of the staff employed very numerous, and the service itself
is highly technical and specialised. This Division is convinced that the interests
of the insane must suffer unless the Board of Health is in direct touch, through
competent representation, with the governing bodies and medical officers of the
Asylums.

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It is submitted that this specialised service should be under the immediate
control of a strong Lunacy Commission in analogy to the Board of Control in
England—the Commissioners being associated with the Board of Health in
whatever manner seems best calculated to ensure the general unity of control
aimed at. The Lunacy Commissioners should be invested with adequate
authority, and it would be possible (subject to the approval of the Lord Chancellor
of Ireland) to place the Commissioners in such relation with the office of the
Registrar in Lunacy that the position of the Commissioners would be fortified
by the Lord Chancellor’s judicial powers, and that the functions of the Board
of Health, the Lunacy Commissioners and the Lord Chancellor’s officers would
be so co-ordinated that there should be no overlapping.

For very many years the law with regard to the insane in Ireland has remained
practically unchanged, and it is only by good will on the part of all concerned that
tolerable conditions are made possible in practice, not as the result of law, but in
spite of it. It is eminently desirable that the law should be codified and brought
up to date, but pending such codification legislation is urgently and particularly
needed to deal with the following matters :

(1) Affecting the patients more directly.

(2) Bearing on the institutions for the insane.

(3) Points primarily affecting the asylum officials.

(4) Auxiliary asylums and “ boarding out.”

(1) Affecting the Patients more directly.

Admission — Discharge — Transfer — Deportation—“ Voluntary Boarders."

Admission. —It has been pointed out that the insane poor should not be treated as
criminals to qualify them for the treatment of their mental disease. The use of the
Dangerous Lunatic Form should be abolished, and patients admitted to asylums on
an amended Form" D " or on an urgency form which shall be mandatory. In any
event the word “ destitute ’’ in this Form “ D ” should be deleted, as it gives rise
to many false declarations, and often operates against the interests of the rate¬
payers. The certification should be uniform. It is anomalous that while one
certificate suffices for a pauper, a “ paying patient ” requires two medical certificates.

Mental Deficiency Act. —That an act on the lines of the Mental Deficiency Act,
1913, be extended to Ireland.

Voluntary boarders. —There seems to be no valid reason why similar facilities
for the admission of voluntary boarders to private, county, and district asylums
should not be extended to Ireland by legislation on the same lines that operated in
England and Scotland.

An alternative legal designation, such as “ county ” or “ borough mental
hospital,” might be arranged as in England.

Discharge. —Legislation should enable the resident medical superintendent to
discharge patients for a prolonged period “ on probation,” and provide that such
patients or their custodians should receive the grant-in-aid until such time as their
names would be removed from the asylum register as “ discharged."

Transfer. —Subject to an agreement between the committees of management of
the asylums concerned, with the concurrence of the next-of-kin (if any), the Commis¬
sioners should have the power on the recommendation of the resident medical
superintendent to transfer patients from one asylum to another for such a period
as may be arranged, and renewed, if necessary, from time to time.

Deportation. —An Act should be introduced to extend to Ireland the provisions
of the Act of Settlement in the matter of Deportation of Lunatics.

(2) Points bearing on the Institutions.

Establishment of Out-clinics—Paying Patients' Department—Affiliation
with a Central Laboratory for Research—Affiliation with Special “Out-clinics ”
( Tuberculosis , Dental and Venereal)—Compulsory Acquisition of Lands for
Asylum Farms—Reform as to the Granting and Removal of Licenses to Private
Asylums—Need of Increased “ Grant-in-Aid."

Out-clinics. —In connection with each asylum, consulting rooms should be
provided (arrangements might be made for the use of the existing dispensaries)

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where voluntary patients would get free advice from one of the asylum medical
officers at certain stated times.

Paying patients' department in district asylums. —The committee of manage¬
ment should be empowered to have in each asylum a ward or division restricted
for the use of patients paying full cost of maintenance, in which such patients would
receive special dietary and clothing when not under treatment in the hospital
division. Such a step would be the means of securing larger contributions for
many patients than at present, when no differentiation is made between the paying,
partially paying and non-paying patients.

The establishment of central laboratory for pathological research in mental and
nervous disease. —Pathological research in insanity is lamentably lacking, and the
optional clause in the Lunacy (Ireland) Act, 1901, relative to the support of such
a laboratory should be made mandatory on county councils and a contribution
levied from them, which, in addition to State grant from sums provided for patho¬
logical research, would suffice to set up a central laboratory in which the assistant
medical officers of asylums should be required to attend during part of their study-
leave to study under the director’s guidance.

Special out-clinics. —If tubercular, dental and venereal out-clinics are set up by
the Public Health Acts, these clinics should be made available for the treatment
of such patients in district asylums as, in the opinion of the resident medical
superintendent, would be suitable cases for investigation and treatment.

Compulsory acquisition of lands for asylum purposes. —As asylum farms supply
the institutions with food, etc., at first cost of production, and are a very great help
to economical management and of importance to the well-being and improvement
of the patients, it would be desirable that committees of management, subject to
the concurrence of the Commissioners, should be empowered to acquire such lands
as they may require approximate to or within easy distance of the institutions,
under somewhat the same terms as lands can be taken for the purposes of the
Labourers (Irel.) Acts. At present committees shrink from competition with the
public.

Licence reform in case of private asylums. —The existing procedure has been com¬
pared as similar to that of the granting of ordinary publicans’ licences, and licences
should only be granted or renewed by the Lord Chancellor on the recommendation
of the Lunacy Commissioners. Such licences should not be given unless the
applicant undertakes to arrange for the insane no less medical care than is
expected for the insane poor. No establishment for the insane should be with¬
out at least one resident medical practitioner.

Need of a subsidiary “ grant-in-aid ” from the Consolidated Fund. —The
transfer of the 4s. "grant-in-aid” from the Consolidated Fund (under the pro¬
visions of the Local Government (Ireland) Act, 1898) eventuated in a considerable
loss to the Irish district asylums, as has been repeatedly pointed out by the com¬
mittees, who feel that they have a very real grievance under that head. As the
"grant-in-aid" was originally given as a moiety of reliefto the cost of maintenance,
which of late years has nearly trebled, it would be but quite equitable to increase
the grant proportionately to the existing high cost. A subsidiary grant from a
non-fluctuating source should be given to make up such deficiency of the 4s. grant
as may arise each year, and at the same time extra grant should be given in relief
of the local rates. It is certain that for many years the cost of maintenance will
be far in excess of any pre-war cost, and it would not be too much to ask the State
to give a grant of 10s. per head weekly, particularly as there are so many senile
cases in lunatic asylums, who would be entitled to that extent of State relief under
the Old Age Pension Act had they not become insane. It must be remembered
also that practically all the patients in district asylums would, if not insane, be the
recipients of State relief under other Acts, such as State Insurance, etc.

(3) Points Primarily Affecting Asylum Officials.

Qualification of Medical Officers—Special Study by Assistant Medical
Officers—Training of the Attendant Staff—Amended Terms of Superannua¬
tion.

The medical qualifications of medical officers. —The enactments of the Local
Government Act of Ireland, 1898, with reference to the qualifications and mode of

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election of asylum medical officers (61 and 62 Vic., Cap. 37), should be retained.
In the case of assistant medical officers they should be amplified. Newly appointed
assistant medical officers should be compelled to take out some recognised special
qualification in mental disease. In the interests of the insane the functions of the
resident medical superintendents as the chief executive officials should be accurately
defined and safeguarded. In the event of legislative changes provision should
be introduced for safeguarding the asylum officials.

Study leave and salaries of assistant medical officers .—The assistant medical
officers, all of whom in a limited service cannot hope to attain senior rank, should
be placed on such terms as would enable them to keep up with general medical
progress, and, if they so desire, to retire after a certain term of years, receiving
a compounded gratuity estimated on their pensionable service. Meantime their
salaries should be such as to enable them to marry, and they should be provided
with suitable residence or rent in lieu thereof. The assistant medical officer,
or, if more than one, the senior, should be entitled ‘‘deputy resident medical
superintendent.”

In connection with the foregoing suggestions the question of converting the
asylum service into a national service might well receive consideration. Weighty
arguments have been brought forward in support of this in the cases of the Poor
Law service, and on grounds of efficiency might be argued with greater force
regarding the asylum service.

Training of attendant staff .—Too much importance cannot be placed on
methods to secure efficient attendant staffs, consequently the Commissioners
should lay down such rules as to training and examination as would be calculated
to secure men and women well fitted for their responsible task. It should be
obligatory on committees to see that such rules are carried into effect. The
staffs should be divided into two classes—“probationary” and "qualified or
trained.” Permanent appointments should be made only from the latter class,
with due regard to age, health and general character.

Need of amendments to Asylum Officers’ Superannuation Act .—In view of the
fact that the terms of the Asylum Officers’ Superannuation Act, 1909, were framed
when the value of money was very considerably higher than the current rates,
the Act requires amendment which was sought for even before the war, viz. the
term of ten years’ service, that on which the calculation for pension has to be made
under the terms of the Act, should be reduced to five at most. Superannuation
on the present terms would in some grades be altogether inadequate to meet the
cost of subsistence.

(4) "Auxiliary Asylums” and “Boarding Out.”

Auxiliary asylums .—In the event of any other system for dealing with the
so-called “harmless insane” being considered necessary, as, for example, in
“auxiliary asylums” as proposed in the Local Government (Ireland) Act, the
Irish Division of the Medico-Psychological Association is of opinion that any
measure of success likely to be met with would be in the direction of creating
such auxiliaries as special “departments” of the existing “district asylums."
The combination of the establishment charges, the facilities for the more
specialised treatment of the insane and the utilisation of an experienced resident
medical staff would secure the most efficient and economical results. In many
places the necessary accommodation would be secured by the adaptation of build¬
ings in the neighbourhood of the asylum ; many country mansions are now in the
market.

“ Boarding out .”—The legislation necessary to permit of a trial of "family care ”
should certainly be enacted. Though there is much against its general success
at the moment, yet at a time when domestic service is an acute problem, many
patients might be located in suitable surroundings with advantage to themselves
and their custodians. This applies more particularly to the agricultural class,
which comprises the vast majority of district asylum patients. The wave of moral
degradation which at present sweeps industrial centres renders the application
of the scheme unsuited to them for the time being.

In conclusion the Irish Division of the Medico-Psychological Association desire

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to reiterate in the strongest terms their conviction that a strong Lunacy Com¬
mission is essential to the efficient administration of everything connected with
the care and treatment of the insane. They urge the constitution of such a
Commission, and the enactment of legislation on the matters dealt with in this
memorandum, giving the necessary legal machinery to initiate the many urgent
reforms so long needed for the betterment of the insane and the general well-being
of the community at large.

MENTAL DISORDERS: STUDY AND TREATMENT IN EARLY

STAGES.

Psychiatric Clinics.

To the Editor of the Times.

Sir, —Permit us through the medium of your columns to draw attention to the
urgent need of reform in the methods of dealing with disorders of the mind in
this country. The insane are still dealt with under the provisions of the Lunacy
Act, 1890. In 1914 the Medico-Psychological Association of Great Britain and
Ireland, after careful inquiry into the status of British Psychiatry, urged reforms in
the methods of treatment of incipient mental disease, and the provision of facilities
for study and research. In November, 1918, this Association adopted a report of
a sub-committee appointed to consider the amendment of the existing lunacy laws.
This report states that there are very few facilities for patients who are threatened
with mental breakdown to obtain skilled treatment until they are placed under
certificates under the Act, whereas the early symptoms of disorder often occur
long before certification is possible; that, owing to treatment being delayed, the
most valuable time for adopting measures to secure early recovery is lost; that
the public, which is alive to the material and moral damage which certification
often inflicts on the patient and his relatives, refuse to resort to it, even when it has
become possible, and thus still further postpone the adoption of efficient treatment;
that where certification has to be resorted to, the subsequent course of events often
shows that this might have been avoided had there been facilities for treatment
under other conditions; that many medical practitioners, having had no oppor¬
tunity of gaining knowledge of the manifestations and treatment of mental disorders
in their early stages, fail to recognise the seriousness of the condition, and are,
further, deterred by the necessity of certifying the patient from advising suitable
treatment.

The existing Lunacy Act, protecting, as it does, society, and safeguarding the
liberty of the subject, allows insufficient scope for the treatment and cure of the
patient.

The position—and we cannot believe that the public can be aware of it—is that
a very large class of the community is debarred from obtaining advice and treat¬
ment (except such as can be given in an out-patient department, and even this
provision is extremely rare), in the early stages of disease, and this owing to the
operation of laws designed mainly with a view to protecting the interests of that
class.

The proposals made by the experts composing this sub-committee to remedy
the defects summarised correctly represent the view of all with practical know¬
ledge of the subject. These aim at the provision of treatment in the early and
curable stages of mental disorder without certification, which provision would be
rendered possible by a short amending Bill to the Lunacy Act, embodying the
reforms most urgently needed. The proposals are, in brief, as follows: The pro¬
vision of clinics—the so-called psychiatric clinics—in large centres of population,
and especially in connection with the general hospitals, and where schools of
medicine exist; the extension of the system of voluntary admission (which now
obtains in respect of licensed houses and registered hospitals for the insane), so
that patients, whether of the private or rate-aided class, may place themselves for
treatment in county borough mental hospitals; or further provision for the private
patient class, so that, with the approval of the Board of Control, such may be

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received without certification (but with the cognisance of the central authority)
into homes, privately owned or supported wholly or partly by voluntary contribu¬
tions, and also into existing public and private mental hospitals (“ licensed
houses”) ; also received, with the sanction of the board, as single patients, without
certification, provided that a medical practitioner gives a written recommendation,
stating that suitable treatment can be obtained in the proposed house.

Of the above proposals, that concerned with the establishment of clinics in
psychiatry—with in- and out-patient departments—as an integral part of the
general hospital system, is the most important. Our main hope of avoiding the
never-ending extensions to existing asylums lies in the operation of these clinics.
In this respect this country is deplorably backward as compared with other
European countries, great and small, with the United States, and with some of
the component parts of the British Empire. This is the more regrettable since it
is in these clinics that students and the future holders of posts in mental hospitals
should be taught and all available means of research be provided. For none of
these purposes is the present “asylum ” system adequate. In such clinics patients
would be received without reception orders or certificates, and would be subjected
to the minimum of official supervision; and on these lines they might be treated
for a stated period—not less than six months. The late Dr. Henry Maudsley was
the first to give practical expression to the urgent need for these clinics when,
eleven years ago, he made his munificent gift—ultimately amounting to £40, 000—
to the London County Council, which rendered possible the erection of the
Maudsley Neurological Hospital, Denmark Hill. This hospital has rendered
most valuable service during the war in the treatment of patients and the instruc¬
tion of medical officers. It is gratifying to think that Dr. Maudsley's wish, that
his hospital should be used for the treatment of early cases of mental disorders,
without certification, and for the teaching of psychiatry, is likely ere long to be
realised.

In this connection it will be of interest to recall that in the case of mentally-
disordered soldiers the Army authorities arranged, during the war, that they be
received into military mental hospitals without any orders or certificates. These
men were, in the first instance, not sent to their asylums until the mental disability
had lasted fora period of nine months and was deemed incurable; later it was
decided that this step should be taken after observation and treatment for such an
extended period as was necessary to form the opinion that recovery was unlikely.
Large numbers of the men were received in very early phases of the disease. The
immense boon and solace this wise step conferred upon the patients and their
relatives are best known to those physicians who have been connected with these
hospitals. If these men could be treated thus whilst in khaki, they could, and
should, be similarly treated as civilians, and under far better medical conditions
than in asylums. The war has in this, as in other instances, been a means of
education.

The necessity of carrying out the reforms above outlined has been repeatedly
urged in the leading organs of the medical profession. That the Board of Control,
the central authority in matters appertaining to the insane, is well aware of the
pressing need for them is sufficiently shown by the recommendations contained in
its fourth and fifth annual reports for the years 1917 and 1918. From the latter
it appears that the Board has submitted to the Lord Chancellor and the Secretary
of State the heads of a Bill, with a recommendation that it should be introduced
into Parliament at the earliest practicable date, and be pressed forward as a
measure of urgent importance to the health and welfare of the people. In October,
1918, a deputation representing the National Council of Mental Hospital Autho¬
rities was received at the Home Office, and it was abundantly clear that that
Department was in sympathy with the representations made with a view to these
reforms. Up to the present time, however, we have no evidence that any step
whatever has been taken to the desired end.

We believe it to be the fact that in the present Parliament there are a number
of medical men and others interested in this matter, and there is a reasonable
hope that such a Bill would meet with sympathy and a swift passage into law.

We would, therefore, earnestly appeal to you to lend your powerful support in
this matter, so that the introduction by the Government of the legislation neces¬
sary to facilitate, on the lines indicated, the early treatment of mental and allied

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nervous disorders may be no longer delayed, and a grievous injustice to a very
large class of suffering humanity may be removed.

We are, Sir,

Your obedient servants,

Pontypridd.

Thomas Barlow.

Clifford Allbutt.

G. H. Savage.

Frederick W. Mott.
Robert Armstrong-Jones.
John Lynn-Thomas.

W. McDougall.

Charles S. Myers.

G. Elliot Smith.

R. Percy Smith.

Bedford Pierce.

Robert B. Wild.

David Drummond.

A. H. Trow.

M. Thomas.

Times, February 6th, 1920. E. Goodall.

MENTAL DISORDERS.

To the Editor of the Times.

University of Edinburgh.

Sir, —As one living under different and happier laws than the writers of the
letter on the above subject, I desire to point out that in Scotland mentally deranged
patients who have means, or whose friends can pay for their support, are able at
the present time to receive curative treatment in any house or home without being
certified to be insane and without being sent to any asylum. Insane patients are
accordingly often sent by physicians from England to Scotland to benefit in this
way by the kindly provisions of its considerate system of laws, and to avoid the
stigma of certification as a lunatic or detention in an English asylum while under¬
going curative treatment. These powers have existed in Scotland for half a
century, and after such a prolonged and completely successful experiment there
should be no hesitation in conferring similar privileges on the people of England,
and in removing not only an invidious but what is to many sensitive persons and
families a most cruel anomaly.

I have, in the second place, to point out to reformers of the lunacy laws that
something more requires to be done than the mere repeal of laws that obstruct
reform and the enactment of others that confer new powers j there is also the
question of financial aid. In Scotland we possess practically all the powers the
signatories desire, but the voluntary treatment of the poor—that is, the State-aided
or parochial class—is for practical purposes a dead letter for this peculiar reason:
that a grant in aid is given by the State for the maintenance of any person who is
certified to be a lunatic, but this grant is withheld, although the patient be treated
on similar medical lines, if he or she be not certified insane. Human nature being
what it is, this is a cause of delay in obtaining treatment, and it encourages the
certification of the patient as a lunatic for the sake of the Government grant,
rather than treatment without certification.

The objects desired by the signatories have the sympathy of everyone engaged
in the care of the mentally afflicted. Our legislators may grant the powers asked
for with an easy mind, as they have existed in Scotland for over 50 years and they
have not been abused. Lastly, the financial problems connected with these
admirable ideals must be carefully worked out, otherwise the powers, if granted,
may be found worthless in practice.

I am,

Yours sincerely,

George M. Robertson,

Times, February 12th, 1920. Professor of Psychiatry.

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THE REPROACH OF PSYCHIATRY IN ENGLAND.

Of all the branches of medicine psychiatry seems still to suffer from that relative
neglect and to labour under those disadvantages which tradition assigns to the lot
of the youngest sister. From time to time the calm of apparent stagnation is
ruffled by some breeze of public agitation seeking to direct attention to defects,
administrative or otherwise, yet such superficial disturbance bears little proportion
to the immense undercurrent of dissatisfaction running strongly, within the pro¬
fession itself, in the minds of all who have the interests of psychiatry in England
at heart. If we inquire the reasons of this they are found to reside in a combina¬
tion of factors on which stress has been laid repeatedly, with as yet little obvious
result. It is imperative that the fons et origo of the dissatisfaction, which percolates
through all the strata of asylum life, should be clearly laid bare, else the stream
will continue to run muddily. It will, we believe, be granted that the scientific
health of the asylum unit—that is, of the medical staff—takes its tone from the
superintendent; should he be keen on the advancement of psychiatric learning,
his subordinates find themselves in a stimulating atmosphere, the influence of
which is reflected in the actual treatment of the inmates, as well as in the con¬
tributions from the staff to the body of psychiatric doctrine. On the other hand,
if the senior has been selected more for social than for scientific equipment, or
should he allow himself to be more concerned with the asylum laundry or meat-
supply than with the healing of the mind, not only is the general scientific level of
the institution lowered, but any junior medical officer is only too apt to find his
youthful enthusiasm starved in an uncongenial environment; he sinks to the
humdrum level of those with whom he is inevitably in such close association.
The asylum officer who can rise superior to depressing surroundings is the excep¬
tion. We should be the last to belittle the importance of social and administrative
gifts in the smooth running of the asylum communities of the country, which from
their very nature must be self-contained and self-sufficient, but psychiatry exists as
a branch of medicine for the prevention and cure of mental disease, and nothing
can ever be permitted to usurp this function. No elaborate schemes of internal
decoration, no ingenuity of kitchen appliances, no perfectly fitted miniature
theatres or admirably supplied gardens, farms and piggeries, can make up for
indifference to clinical and pathological reports, neglect of modern technique in
treatment, or absence of stimulus to increase the annual percentage of cures or
relief.

The promotion or advancement of a medical officer, further, sometimes seems
to depend so little on his professional knowledge that he has scant inducement to
devote himself to an earnest study of the subject. His work is too often seen to
begin and end with the discharge of routine—essential duties which fatigue without
stimulating—and with the accomplishment of which any incentive to personal
research vanishes. When he has time to think over things he fully realises the
tremendous material at his disposal, the fascination of the study of the complex
case, the therapeutic problems with which he is surrounded, yet evening finds him
unable or disinclined to sit down to serious work. There is, however, another
reason for the paucity of scientific output. Friendly conversation with the average
asylum medical officer has often elicited the confession that he does not know how
or where to begin his task; he is conscious of not being abreast of knowledge in
many instances, and is sorely in lack of a guiding and advising mind. If this
position be analysed it will be seen to derive from the fact that so few centres for
the organised teaching of psychiatry exist, and the equipment of some leaves much
to be desired. Of how many of our asylum officers can it be said that they
have attended courses of theoretic and practical psychiatry at home or abroad ?
When do they get a four or six weeks’ leave of absence to follow post-graduate
instruction in their life’s work at a recognised centre? Nay, how many of them
have ever spent an unforgettable Wanderjahr in foreign school or laboratory prior
to their entering on their professional career of psychiatric expert ? Not that
foreign experience of itself confers a cachet unobtainable at home, for our home
material, in no way inferior, is calling out for investigation and research ; but as
long as our young medical officers drift untrained into asylum work, so long will
the reproach continue that in this country psychiatry is not adequately studied.

On other occasions we have spoken of the peculiar restrictions and handicaps of

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NOTES AND NEWS.

[April,

certain phases of asylum life for the junior staff ; we are more concerned for the
present to appeal emphatically for better chances for training, better facilities to
keep abreast of scientific advance, greater endeavour to make the first step on the
ladder encouraging, more serious efforts to utilise precious time and valuable stuff.
Is it too much to hope that the authorities who control asylum affairs should one
day claim a certain standard of professional attainment on the part of medical
officers entering the service, and insist similarly on granting members of asylum
staffs post-graduate leave ? We are confident that the outlook is bright in reality,
and that the stirring among what only the cynic would call the dry bones augurs
well for the future. We can imagine a central authority fully conversant with the
best methods employed in the whole range of the practice of psychiatry, and able
to give local bodies information and guidance as to management, equipment, and
expectation of output on the scientific side no less than on the others ; we can
foresee the day when prophylaxis and prevention will be elevated to their true
importance by the establishment of clinics and observation wards staffed by trained
men with all-round experience. The problem confronting us is the elaboration of
the best way to organise and utilise the sources of psychiatric energy which, we are
convinced, are only waiting to be tapped.— Lancet, March 6th, 1920.

NURSES REGISTRATION ACT, 1919. ENGLAND AND WALES.(‘)

9 & 10 Geo. 5, Ch. 94. 23^ December 1919.

1. —(1) For the purposes of this Act, there shall be established a General
Nursing Council for England and Wales (in this Act referred to as " the Council ”),
which shall be a body corporate by that name with perpetual succession and a
common seal with power to acquire and hold land without licence in mortmain.

(2) The Council shall be constituted in accordance with the provisions con¬
tained in the Schedule to this Act.

(3) The seal of the Council shall be authenticated n the prescribed manner
and any document purporting to be sealed with the said seal so authenticated
shall be receivable in evidence of the particulars stated in that document.

2. —(1) It shall be the duty of the Council to form and keep a register of nurses
for the sick in this Act referred to as “the register”) subject to and in accordance
with the provisions of this Act.

(2) The register shall consist of the following parts:—(a) a general part
containing the names of all nurses who satisfy the conditions of admission to
that part of the register: ( b ) a supplementary part containing the names of male
nurses: ( c ) a supplementary part containing the names of nurses trained in the
nursing and care of persons suffering from mental diseases: ( d) a supplementary
part containing the names of nurses trained in the nursing of sick children:
(e) any other prescribed part.

Where any person satisfies the conditions of admission to any supplementary
or prescribed part of the register, his name may be included in that part of the
register notwithstanding that it is also included in the general part.

(3) A certificate under the seal of the Council duly authenticated in the
prescribed manner stating that any person is, or was at any date, or is not, or
was not at any date, duly registered under this Act shall be conclusive evidence in
all courts of law of the fact stated in the certificate.

(4) Any reference in this Act to the register shall, unless the context otherwise
requires, be deemed to include a reference to any part of the register, and the
expression “registered” shall be construed accordingly.

3. —(1) The Council shall make rules for the following purposes:—(a) for
regulating the formation, maintenance and publication of the register; (b) for
regulating the conditions of admission to the register; (c) for regulating the
conduct of any examinations which may be prescribed as a condition of admission
to the register, and any matters ancillary to or connected with any such examina¬
tions ; ( d ) for prescribing the causes for which, the conditions under which, and
the manner in which nurses may be removed from the register, the procedure
for the restoration to the register of nurses who have been removed therefrom,
and the fee to be payable on such restoration; (e) for regulating the summoning

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of meetings of the Council and the proceedings (including quorum) of the
Council; (/) for enabling the council to constitute committees and for authorising
the delegation to committees of any of the powers of the Council, and for
regulating the proceedings (including quorum) of committees; (g) generally for
making provision with respect to any matters with respect to which the Council
think that provision should be made for the purpose of carrying this Act into
effect (including provision with respect to the issue of certificates to nurses
registered under this Act and with respect to the uniform or badge which may
be worn by nurses so registered), and for prescribing anything which under this
Act is to be prescribed.

(2) Rules under this section shall contain provisions— (a) requiring as a con¬
dition of the admission of any person to the register that that person shall have
undergone the prescribed training, and shall possess the prescribed experience, in
the nursing of the sick ; and ( b) requiring that the prescribed training shall be
carried out either in an institution approved by the Council in that behalf or in the
service of the Admiralty, the Army Council, or the Air Council; and (c) enabling
persons who, within a period of two years after the date on which the rules to be
made under the provisions of this paragraph first come into operation, make an
application in that behalf (in this Act referred to as “ an existing nurse’s applica¬
tion ”), to be admitted to the register on producing evidence to the satisfaction of
the Council that they are of good character, are of the prescribed age, are persons
who were for at least three years before the first day of November, nineteen
hundred and nineteen, bond fide engaged in practice as nurses in attendance on
the sick under conditions which appear to the Council to be satisfactory for the
purposes of this provision and have adequate knowledge and experience of the
nursing of the sick.

(3) Rules made under this section shall not come into operation unless and
until they are approved by the Minister of Health.

(4) Every rule made under this section shall be laid before each House of
Parliament forthwith, and, if an Address is presented to His Majesty by either
House of Parliament within the next subsequent twenty-one days on which that
House has sat next day after any such rule is laid before it praying that the
rule may be annulled or modified, His Majesty in Council may annul or modify
the rule, and, if annulled, it shall thenceforth be void, and, if modified, it shall
thenceforth have effect as so modified, but without prejudice to the validity of
anything previously done thereunder.

4. —(1) The Council may, with the previous sanction of the Minister of Health,
appoint a person to act as registrar of the Council, and may, subject to the consent
of the Minister as to numbers, employ such other officers as the Council consider
necessary.

(2) There shall be paid to the registrar and the officers of the Council such
salaries or remuneration as the Council with the approval of the Minister of
Health may from time to time determine.

(3) Any expenses incurred by the Council in carrying this Act into effect,
including expenses in connection with examinations or prosecutions under this
Act and, subject as hereinafter provided, the travelling expenses of and sums paid
on account of subsistence allowance to members of the Council, shall be defrayed
out of the sums received by the Council by way of fees under this Act:

Provided that the amount to be allowed to members of the Council in respect of
travelling expenses and subsistence allowance shall be calculated in accordance
with directions to be given by the Minister of Health.

(4) The accounts of the Council shall be audited in such manner, and by such
person, as the Minister of Health may from time to time direct, and copies of the
accounts, and of any report made on the accounts, shall be transmitted by the
Council to such persons as the Minister may direct.

5. —(1) There shall be paid to the Council in respect of every application to be
examined or to be registered under this Act, and in respect of the retention in any
year of the name of any person on the register, such fees respectively as the Council
may, with the approval of the Minister of Health, from time to time determine:

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of the fee payable in respect of the retention in any year of the name of any person
on the register shall not exceed two shillings and sixpence.

(2) The Council may charge for any certificate or other document issued, or in
respect of any services performed, by them, such fees as may be prescribed.

6. —(1) Any person who proves to the satisfaction of the Council that he has
been registered either generally as a nurse for the sick or as a nurse of some
special class in any part of His Majesty’s dominions outside the United Kingdom,
being a part of those dominions to which this section applies, shall be entitled, on
making an application in the prescribed manner and paying such fee, not being
greater than the fee payable on ordinary applications for registration under this
Act, as the Council may demand, to be registered in a corresponding manner
under this Act.

(2) This section applies to any part of His Majesty’s dominions as respects
which the Council are satisfied— (a) that there is in force therein an enactment,
or a provision of any kind having the force of law, providing for the registration
of nurses under some public authority; (b) that persons registered under this Act
are admitted to the register established under the said enactment or provision on
terms not less favourable than those contained in subsection (1) of this section
and (c) that the standard of training and examination required for admission to
the register of nurses established under the said enactment or provision is not
lower than the standard of training and examination required under the Act.

(3) In the event of provision being hereafter made for the establish me ntof a
register of nurses in Scotland or Ireland, the Council shall make rules under this
Act enabling persons registered as nurses in Scotland or Ireland, as the case may
be, to obtain admission to the register of nurses established under this Act; and,
with a view to securing a uniform standard of qualification in all parts of the
United Kingdom, the Council shall, before making any rules under this Act with
respect to the conditions of admission to the register, consult with any Nursing
Councils which may be established by Parliament for Scotland and Ireland
respectively.

7. —(1) Any person aggrieved by the removal of his name from the register may,
within three months after the date on which notice is given to him by the Council
that his name has been so removed, appeal against the removal in manner pro¬
vided by rules of court to the High Court, and on any such appeal the High Court
may give such directions in the matter as it thinks proper, including directions as
to the costs of the appeal, and the order of the High Court shall be final and
conclusive and not subject to an appeal to any other court.

(2) Any person aggrieved by the refusal of the Council to approve any insti¬
tution for the purpose of the rules under this Act relating to training may appeal
against the refusal to the Minister of Health, and the Minister, after considering
the matter, shall give such directions therein as he thinks proper, and the Council
shall comply with any directions so given.

8. —(1) Any person who—(a) not being a person duly registered under this Act,
at any time after the expiration of three months from the date on which the
Minister of Health gives public notice that a register of nurses has been compiled
under this Act, takes or uses the name or title of registered nurse, either alone or
in combination with any other words or letters, or any name, title, addition,
description, uniform, or badge, implying that he is registered under this Act or is
recognised by law as a registered nurse; or ( 4 ) being a person whose name is
included in any part of the register, at any time after the expiration of the period
aforesaid takes or uses any name, title, addition, description, uniform or badge, or
otherwise does any act of any kind, implying that his name is included in some
other part of the register; or (c) at any time with intent to deceive makes use of
any certificate of registration as a nurse issued under this Act to him or any other
person, shall be liable on summary conviction to a fine not exceeding, in the case
of a first offence, ten pounds, and in the case of a second or any subsequent offence
fifty pounds.

(2) If any person wilfully makes, or causes to be made, any falsification in any
matter relating to the register, he shall be guilty of a misdemeanour and shall, on
conviction thereof, be liable to a fine not exceeding one hundred pounds.

9. —(1) This Act shall not extend to Scotland or Ireland.

(2) This Act maybe cited as the Nurses Registration Act, 1919.

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Schedule.

Constitution of Council.

1. The Council shall consist of twenty-five members.

2. On its first constitution the Council shall be composed of the following
persons, namely:

Two persons, who shall not be registered medical practitioners, or nurses, or
persons concerned with the regular direction or provision of the services
of nurses, appointed by the Privy Council:

Two persons appointed by the Board of Education :

Five persons appointed by the Minister of Health, after consultation with
persons and bodies having special knowledge and experience of training
schools for nurses, of the work of matrons of hospitals, of general and
special nursing services, and of general and special medical practice:

Sixteen persons, who are or have at some time been nurses actually engaged
in rendering services in direct connection with the nursing of the sick,
appointed by the Minister of Health after consultation with the Central
Committee for the State Registration of Nurses, the College of Nursing,
the Royal British Nurses’ Association, and such other associations or
organised bodies of nurses or matrons as represent to the Minister that
they desire to be consulted in the matter.

The Minister, in making appointments under this provision, shall have
regard to the desirability of including in the Council persons having
experience in the various forms of nursing.

3. The first members of the Council shall hold office for such term, not less than
two years and not exceeding three years from the commencement of this Act, as
the Minister of Health may determine.

4. After the expiration of the term of office of the first members of the Council,
the Council shall be composed of nine persons appointed respectively by the Privy
Council, the Board of Education, and the Minister of Health as aforesaid, and of
sixteen persons, being persons registered as nurses under this Act, elected in
accordance with the prescribed scheme and in the prescribed manner by the persons
so registered at the date of election.

5. Any members of the Council other than the first members thereof shall hold
office for a term of five years.

6. If the place of a member of the Council becomes vacant before the expiration
of his term of office whether by death, resignation, or otherwise, the vacancy shall
be filled by appointment by the body or persons by whom the member was appointed,
or if the vacating member was an elected member by the Council.

The Council in co-opting a member under the foregoing provision shall, so far
as practicable, select a person, being a person registered as a nurse under this Act,
who is representative of the same interests as those represented by the vacating
member.

Any person appointed or elected to fill a casual vacancy shall hold office only so
long as the member in whose stead he is appointed or elected would have held office.

7. Any member ceasing to be a member of the Council shall be eligible for
re-appointment or re-election.

8. The powers of the Council may be exercised notwithstanding any vacancy in
their number.

(*) The Nurses Registration (Scotland) Act, 1919, will be printed in the July
number.

LONDON COUNTY COUNCIL.

Lectures and Practical Courses of Instruction at the Maudsley
Hospital, Denmark Hill, S.E. 5, for a Diploma of Psychological
Medicine, 1920.

Part I.

1. Twelve Lectures on the Anatomy of the Nervous System. By Sir Frederick
Mott, K.B.E., M.D., LL.D., F.R.S., F.R.C.P.

Practical Instruction and Demonstrations. (8 Sessions of two hours each.)

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194 NOTES AND NEWS. [April,

2. Twelve Lectures on the Physiology of the Nervous System. By F. Golla,
M.D., F.R.C.P., Physician, St. George’s Hospital.

Practical Physiology, (to Sessions.) By F. Golla, M.D., F.R.C.P. (The
Object of this Course is to put students in possession of such methods as might
be employed in minor research work in mental diseases.)

3. Ten Lectures on Psychology. By J. V. Lowson, M.A., M.D.Edin.,
Demonstrator of Psychology, University of Cambridge.

Practical Psychology. Practical Work and Demonstrations. (8 Sessions.)
By J. V. Lowson, M.A., M.D.Edin.

Part II.

1. Twelve Lectures on the Diagnosis, Prognosis and Treatment of Mental
Diseases. By C. Hubert Bond, D.Sc.,'M.D., F.R.C.P.

2. Two Lectures on Crime and Responsibility. By Sir H. Bryan Donkin,
M.D., F.R.C.P.

3. Two Lectures with Demonstrations of Cases on the Practical Aspect of
Mental Deficiency. By F. C. Shrubsall, M.D., F.R.C.P. (Principal Assistant
Medical Officer, Public Health Department, L.C.C.)

4. Six Lectures on the Pathology of Mental Diseases including Brain Syphilis,
its Symptomatology and Treatment, with Demonstrations. By Sir F. W. Mott,
K.B.E., M.D., F.R.S.

5. Eight Lectures on the Psychology of Conduct. By William MacDougall,
M.A., M.D., F.R.S.

6. Twelve Clinical Demonstrations in Neurology. By F. Golla, M.D., F.R.C.P.,
and Sir Frederick Mott, K.B.E., M.D., F.R.S.

7. Six Lectures on the Psychoneuroses. Bv Bernard Hart, M.D. (Physician
Mental Disease University College Hospital, Lecturer in Mental Disease,
University of London).

Fees.

For the Whole Course of Part I and Part II
For Part I separately ....

For Part II separately ....

For either Group 1 or Group 2 of Part II

(Group 1 consists of Sessions 1, 2, 3, 4; Group 2 consists of Sessions 5, 6 and 7.)

Applications for forms of admission to the Course should be made to the
Asylums Officer, 13, Arundel Street, Strand, W.C. 2.

The Fellowship of Medicine, 1, Wimpole Street, W., will collect fees from, and
issue admission tickets to, medical men intending to take the course, who are
introduced by the Fellowship.

LIBRARY FOR DEAF EDUCATION.

In connection with the Ellis Llwyd Jones Lectureship for Training Teachers of
the Deaf, recently established at the University of Manchester through the bene¬
faction of Sir James E. Jones, the Carnegie United Kingdom Trust has generously
granted to the University the sum of ,£2,500 for the foundation and maintenance
of a Library for Deaf Education. It is intended to make this Library as compre¬
hensive as possible, and to include in it works dealing with the various systems
of teaching the deaf—speech training, psychology of speech and hearing, phonetics,
acoustics, anatomy, physiology, and diseases of the ear. The books are to be
available to all individuals, societies and institutions throughout the United
Kingdom interested or concerned in the education and training of the deaf, and
they will be ready for consultation and borrowing immediately after Easter, 1920.

No charge, beyond the cost of carriage, is made for the loan of books, but
intending borrowers are required to fill in a form of application to be obtained
from ‘‘The Librarian, Library for Deaf Education, The University, Manchester.”

(Signed) Chas. Leigh,

Librarian.

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NOTES AND NEWS.

195

OBITUARY.

Dr. Edwin Lindsay Dunn,

Late Medical Superintendent of the Berkshire Asylum, Wallingford.

I feel great diffidence in writing the obituary notice of Edwin Lindsay Dunn,
for I realise how inadequate is my pen to do full justice to the task. The son of
the late Mr. Robert Dunn, of Dunfield, Waterside, Ireland, he was born in 1865
and received his early education at Foyle College, Londonderry, winning a scholar¬
ship in 1876. The examiner on that occasion was Mr. J. H. M. Campbell, then
Scholar and Senior Moderator of Trinity College, Dublin, who reported on “the
splendid answering in every subject of Dunn.” He thus gave evidence, even at so
tender an age, of those remarkable talents which characterised his more mature
years. His school career was throughout most brilliant, and after being an Inter¬
mediate Exhibitioner 1879-1880 and a Matriculation Exhibitioner, R.U.I., 1881,
he entered Trinity College, Dublin, as First Junior Exhibitioner in 1882. There
he continued his successful career, taking his B.A. degree with Honours in Classics
and English Literature. He then decided upon medicine as a profession, and after
taking Honours in Anatomy, and incidentally holding the posts of Resident Pupil,
Dr. Steevens' Hospital, Dublin,Clinical Clerk and Surgical Dresser, Sir P. Dun's
Hospital, Dublin, and Prosector to the University Anatomist, he received the
degrees of M.B., B.Ch. in 1887. He was later appointed Assistant House-Surgeon
to the Children’s Infirmary, Liverpool, Assistant Surgeon, Liverpool Dispensaries,
and, upon adopting lunacy practice as a career, Assistant Medical Officer at the
West Riding Asylum, Wakefield. At Wakefield Asylum he made several con¬
tributions to medical literature, including “ Cases of Epilepsy Treated by Amylene
Hydrate,” “Case of Softening of the Sensory Tract of Internal Capsule,” and
“Case of Homonymous Hemianopsia.” Dunn's paper on " Paranoia,” read at the
Psychology Section of the British Medical Association at Nottingham in July, 1892,
was a noteworthy addition to our knowledge of that disease, although cases had
been recognised in England before then. He was a member of the Medico-Psycho¬
logical Association, a member of many years’ standing of the British Medical
Association, and a prominent member of the Reading Pathological Society. He
was appointed Senior Assistant Medical Officer and Deputy Medical Superintendent
of the Berkshire Asylum, Wallingford, in 1894, and on the death of Dr. Murdoch
succeeded him as Medical Superintendent.

Outside his professional work, literature, Freemasonry and sport appealed most
to him. At school he was a member of the Fifteen and a good runner, at Trinity
College, Dublin, a prominent oarsman, rowing for the University Boat Club and
winning many races, and a member of the University Fifteen. He also played for
the famous Wanderers Club, but although well in the running for International
honours was not capped for Ireland—a fact which always caused him keen regret.
He was fond of shooting and golf, and a good fisherman, his proudest trophy being
a fine Thames trout, scaling lbs., which he caught at Pangbourne.

Dunn was an enthusiastic Freemason, and was installed Worshipful Master of the
St. Hilda Lodge, Wallingford, in 1890. He excelled as a raconteur and after-
dinner speaker, and a speech he once made in aid of the Masonic Charities will live
in the history of the St. Hilda Lodge.

He was extremely well-read, and could talk with knowledge, and in his own
delightfully original way, on any subject. Politics, religion—his knowledge of the
Bible was profound—science, sport, literature, nothing came amiss to him. He
read Greek for pleasure, and was very fond of French literature.

He was a true Irishman, genial, quick-tempered, impulsive, generous to a fault,
the soul of hospitality, extremely witty, excellent at repartee. I remember his
once being stopped in Oxford by a particularly dirty tramp, who tried to sell him a
cake of soap, and Dunn’s reply, “ I'm afraid you can’t spare it, my man, but here’s
twopence for you.” His laugh, apart from his sunny disposition and high spirits,
was the most infectious thing about him. No one who ever heard it could readily
forget it. He had a genius for making friends and for keeping them, and his red
jovial face, merry blue eye and inimitable laugh will be sadly missed. The Visit¬
ing Committee of the Asylum were his personal friends; he was beloved by his
patients and staff, to whom his sympathy, advice and help were always open.

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A devoted son and brother, his mother's death a few years ago was a great blow
to him. His own death occurred on January 12th, after several weeks of great
pain and suffering borne with wonderful patience and fortitude. He was un¬
married. He leaves a sister to mourn his loss, and to her I am indebted for much
of the information here recorded. P. C. Coombes.

Dr. J. Barfield Adams.

The short illness and sudden death, at the age of sixty, of Dr. J. Barfield Adams
on February 20th, 1920, while returning from some professional call, came as a great
shock to his medical brethren in North Bristol, where he had practised in general
medicine for over thirty-five years. About eight years previously he had had to
take a rare and enforced holiday in Holland and Belgium and Northern France
owing to a first attack of angina pectoris, but he returned to his duties quite as
devotedly and almost as strenuously as before, and carried on ever since. Though
he had repeated warnings of the same kind, and his heart must have latterly begun
to fail seriously, none of us who saw him in the last few weeks and even on the day
of his death, going about much as usual, had any suspicion of impending danger ;
the more so as he had always been a man of great reserve where he himself was
personally concerned.

He received his medical education in the Edinburgh University and Extra
Mural Medical School, and obtained the Edinburgh Triple Qualification in 1882.
From the interest he took and the knowledge he displayed in matters medico-
psychological I think he must have had asylum experience, though I have no
record as yet as to where he did duty. For the last dozen years he held the respon¬
sible post of Medical Officer to the Bristol Colston's Girls’ School. He became a
member of the Medico-Psychological Association in 1913, and about the same time
obtained the Certificate in Psychological Medicine of the Association. While his
chosen life-work was to be a general medical practitioner of the best type, he was
one of these medical men (all too few as yet) who take an intense interest in
psychiatry as bearing on their daily work in medicine. Long and happily married,
he left no children to mourn his loss.

In the last few years, and more especially during the war, he undertook regular
work for the Journal of Mental Science, and contributed valuable critical epitomes
of current medico-psychological literature, irradiating his views with sympathy,
humour, and occasionally with gentle dissent. Himself a literary artist and a
master of style, he also contributed two original delightful critical studies to the
Journal of Mental Science, namely " Zola’s Study of Heredity ” (July, 1916), and a
complemental “ Zola’s Studies in Mental Disease ” (April, 1917). A discriminating
admirer of one whom he dubbed “ Master,” he freely points out where he thinks
Zola failed to be quite true to nature in some of his cameos of insane and degene¬
rate characters. In a third contribution to the Journal, "The Orientation of
Human and Animal Figures in Art” (October, 1917), he successfully broke new
ground, revealing a wealth of erudition and a playfulness of humour worthy of
De Quincy, combined with an insight into pictorial art, and a personal acquaintance
with experimental pedagogics quite remarkable. In the same vein about the
same time he contributed two essays on Zola to other journals entitled “ The
Doctors in Zola’s History of the Rougon-Mackquart Family," and “ Dr. Pascal
Rougon : Zola’s Study of a Savant.”

He told me once that after graduating he had toured on a bicycle throughout the
highways and bye-ways of Northern France, with a view mainly to a study of
French ecclesiastical architecture. Each cathedral was to him no mere local lion,
but an organic whole, showing in the details of its structure within and without its
own particular history and that of the ages it had weathered. He was a finished
French scholar both in speech and in literary knowledge. In later years he took
up the study of Italian ("The Doctors in the Decameron”), Spanish, and even
Welsh (“ Medicine and Surgery in the Mabimogion ”). Whether he ever studied the
"gentle German language” is not very apparent; if he did (as is possible) he
allowed no pestilent whiff of latter-day Teutonic kultur to obscure his clear vision
into Gallic esprit.

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NOTES AND NEWS.

197

He took great pleasure in studying what Charles Reade called the " poor dear
doctors ” themselves (and incidentally some of their patients) as mirrored in
literature, and more especially in that of his beloved France.

Others (friends and patients of this quiet, many-sided man), who knew him more
intimately, could doubtless say much of him from their several points of view. It
suffices here to say that to those of us, his professional brethren, who met him only
Occasionally on our daily rounds, he was a dignified, kindly man of the highest
personal and professional ideals, wise in counsel, and a stimulating listener, who in
any subject of conversation was willingly allowed to make the deciding judgment.
One might apply to him the remarks he makes himself on one of his favourite
characters in Zola, “ the savant," Dr. Pascal Rougon: “ He had a profound
contempt for all that was mean or ignoble—the few who were admitted to his
friendship loved him for his honesty and goodness of heart, and admired him for
his devotion to work." W. Cotton.

Dr. Elmer E. Southard,

Bullard•Professor of Neuropathology, Harvard Medical School.

The death in New York on February 8th, 1920, from pneumonia after an illness
of two days of Dr. Elmer E. Southard, of Cambridge, America, will be learned with
much regret by readers of the Journal and members generally of the Medico-
Psychological Association.

Dr. Southard was born in Boston on July 28th, 1876, and graduated in Arts
at Harvard College in 1897, and at Harvard Medical School in 1902. After
studying at Frankfort and Heidelburg he entered the City Hospital, Boston, as
Interne and Assistant in Pathology in 1901, and three years later he became
Instructor of Neuropathology at the Harvard Medical School. In 1906 he
became Assistant Physician and Pathologist of the Danvers State Hospital,
and in 1909 he was made Bullard Professor of Neuropathology at the Harvard
Medical School and appointed Pathologist to the Massachusetts State Board
of Insanity. Since 1912 he had been Director of the Boston Psychopathic
Hospital. He was also Pathologist to the Massachusetts Commission on Mental
Diseases. He was associate editor of the Journal of Nervous ami Mental Diseases
and assistant editor of Epilepsia. In 1917 he was attached to George Washington
University, and during the war was a major in the Chemical Warfare Service.

He collaborated in the production of a recent work on Shell Shock and Neuro¬
psychiatry, and made many valuable contributions on neuropathology and mental
hygiene to current American psychiatry, and his wide knowledge and influence as
regards these and allied subjects were recognised both at home and abroad.

The respect and trust his countrymen reposed in him is shown by the fact that
he was a member of the Board of Associated Charities of Boston and of the
American Academy of Arts and Sciences. He had been President of the Boston
Society of Psychiatry and Neurology and President of the American Medico-
Psychological Association.

He was stricken when fulfilling a series of important engagements before several
medical bodies, and the day before had addressed the National Committee for
Mental Hygiene at the Academy of Medicine, New York.

He was one of America’s foremost amateur chess players and a member of St.
Botolph and Boston Chess Clubs.

His loss was much mourned in America, and the memorial service held at
Appleton Chapel, Cambridge, was attended by Harvard professors, students,
members of the State Board of Health, and many others. He had reached the
stage of maturity and greatest usefulness, and a brilliant future was before
him. His great patterns were Prof. Royce and Prof. James, whose ideals were
reflected in much that he did. An enthusiastic writer, with a cheerful and attractive
personality, his whole thought was how best to serve humanity. It is for others
now to continue in his footsteps, and his many friends and admirers, who owe so
much to him, will see that his teachings are not lost to posterity but continued and
amplified as if he were yet with them.

His helpmate in life was Dr. Mabel Fletcher Austin of Boston, whom he married
in 1906. J. R. L.

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NOTES AND NEWS.

[April, 1920.

NOTICES OF MEETINGS.

Annual Meeting.

The Buxton Town Council have officially invited the Association to hold their
Annual Meeting there this year, and the following is a short summary of the
arrangements made :

Monday , July 26th. —Committees meet as early after lunch as members can arrive.

Tuesday, 27/A.—Spent at Cheddleton. Committees, Council, etc., at 10 a.m.
Lunch for ladies and members 1 p.m. Annual Meeting 2 p.m. Visit to silk mill
at Leek or to pottery at Hanley in forenoon. Garden party 3.30 p.m. Annual
Dinner, Buxton (members and ladies), 8.30. Motor char-a-bancs will be arranged
for. Buxton to Leek 12 miles, south (rise and fall of over 1,500 ft. between),
Leek to Cheddleton 3 miles, south.

Wednesday, 28/A.—Scientific discussions, Town Hall, Buxton, 10 a.m. Half¬
day excursion for ladies in the forenoon. A reception may be arranged in the
Town Gardens for the afternoon.

Thursday, 29/A.—Full-day excursion to Haddon Hall and Chatsworth. If more
papers are promised, so that a meeting on Thursday morning becomes desirable,
half-day excursion will be arranged for Thursday afternoon, and the Haddon Hall
excursion on Friday if members will stay, in view of the fact that the following
Monday is Bank Holiday.

HOTEL ARRANGEMENTS should be made at Buxton at once, as the end of
July is the height of the local season and lodgings become unobtainable.

The following hotel accommodation at Buxton is recommended: Palace Hotel,
Crescent Hotel, St. Ann’s Hotel, Buxton Hydro, Haddon Hall Hydro, Olivers
Hydro, Sandringham Hotel, Milton House, Old Hall Hotel, Shakespeare Hotel,
Pendennis, George Hotel, Pavilion.

Divisional Meetings.

South-Eastern Division. —May 5th, Littleton Hall, Brentwood, Essex.

South-Western Division. —April 23rd, Portsmouth Mental Hospital.

Northern and Midland Division. —April 29th, Mental Hospital, Middlesbrough.

Irish Division. —June 24th and November 4th, 1920 ; April 7th, 1921 ; July 7th,
1921.

NOTICE BY REGISTRAR.

Dates of Examination for Nursing Certificates.

May 3rd.Preliminary.

„ 10th.Final.

REVIEWS.

The Editors regret that the notices of the Report of the Board of Control and
Mental Hospitals and Asylums Reports generally are again unavoidably postponed.

NOTICE TO CONTRIBUTORS.

N.B. —The Editors will be glad to receive contributions of interest, clinical
records, etc., from members (whether these have been read at meetings or not)
for publication in the Journal. They will also feel obliged if contributors will
send in their papers at as early a date as possible in each quarter.

Writers are reminded that, according to Lix(a) of the Articles of Association,
“ all papers read at the Annual, General, or Divisional Meetings of the Association
shall be the property of the Association, unless the author shall have previously
obtained the written consent of the Editors to the contrary.”

Papers read at Association Meetings should not, therefore, be published in other
Journals without such sanction having been previously granted.

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THE

JOURNAL OF MENTAL SCIENCE

[Published by Authority of the Medico-Psychological Association
of Great Britain and Ireland.']

No. 274 [^ 0 "r] JULY, 1920. Vol. LXVI.

Part I.—Original Articles.

The First Maudsley Lecture, delivered by Sir James Crichton-
Browne, D.Sc.Leeds, M.D.Edin., Hon. LL.D.St.And. and
Aberd., F.R.S.Lond. and Edin., Lord Chancellor’s Visitor in
Lunacy, at the Quarterly Meeting of the Medico-Psychological
Association of Great Britain and Ireland, held at the House of the
Royal Society of Medicine, London, on May 20th, 1920.

Gentlemen, —I feel I owe the honour of having been selected to
deliver this first Maudsley Lecture, not to any special fitness I possess
to expone any of the more recent developments of that branch of
medicine, the furtherance of which the lectureship is intended to pro¬
mote, but to the fact that I am almost the last survivor of those who
were associated with the founder of the lectureship in the early days of
his professional career. While still a student at the University, Maudsley
was revealed to me in a brilliant essay on Edgar Allan Poe, which was
published in the Journal of Mental Science in April, 1860, and which,
although too scathing and denunciatory of the ill-fated poet, as it now
appears, was so rich in insight, originality and happy similitudes as to
betoken unmistakably “ the lighting of another taper at Heaven,” which
was at that time Maudsley’s way of describing the arrival of a new man
of genius on the scene. A few years later I made Maudsley’s personal
acquaintance at the table of that gracefully-refined and highly-gifted
physician and philanthropist, Dr. John Conolly, who afterwards became
his father-in-law, and in the years following I can recall many
memorable meetings with him at “ The Lawn,” at Hanwell, in his rooms
in Queen Anne Street, and in a restaurant in Soho, where, over frugal
meals, he and I and Lockhart Robertson, and Broadbent and
Harrington Tuke and Baron Mundy of Moravia, the zealous advocate
of non-sequestration and family life and free air for the insane, held
high discourse and adumbrated projects for the future of lunacy, some
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of which have taken shape since then, while others remain unrealised
and perhaps unrealisable.

Maudsley’s pathway and mine diverged physically after these racy
and roseate London days, when my lot was cast in the provinces for a
decade, and they diverged spiritually also, for he abandoned the
teleological platform on which we both started and advanced into
scientific materialism and agnosticism, where I could not then follow
him. But whatever differences of conviction and outlook separated us,
our friendship remained unbroken to the end. I cannot claim to have
been one of what was, I believe, the very small circle of his intimates,
but I was never estranged from him by quarrel or misunderstanding,
and the admiration and esteem in which I held him never for a moment
paled.

I have not the material for even a biographical sketch of Maudsley if
I desired to present one to you, and any such sketch would be of only
ephemeral and partial interest, for we shall, I trust, have, one of these
days, an adequate record of a life prosperous and uneventful, but rich
in fruitful endeavour and leaving a distinctive mark on the philosophical
history of the latter half of the nineteenth century. An appreciation of
Maudsley’s achievements such as the time-limit here would permit is
still less feasible, and would be somewhat superfluous after the generous
and sympathetic but discriminating obituary notices which we owe to
Sir George Savage and Sir Frederick Mott, and would, moreover, be
out of place, for I am sure the last thing the donor of this lectureship,
retiring and shy of publicity as he was, would have wished would be
that its inaugural discourse should be devoted to any elaborate eulogy
of himself. Let me just say of him that in every situation in life, in the
domestic circle, in society, in the lecture-room, by the bedside] and in
the witness-box he “ gave the world assurance of a man,” and of a man
of a striking and unique personality, of keen and decisive intellect, and
of a courageons and independent temper. Of tough Yorkshire fibre,
deftly woven, Maudsley had in him a dash of the gloom and austerity
of “ Wuthering Heights,” but that was lit up by the sunshine of a liberal
culture and by genuine goodness of heart. He was cynical and
sententious betimes, but the tartness of his tongue was belied by his
genial smile, and the pessimism he preached was discounted by the
charity he practised. Enemies he had, for he had no tolerance of fools,
and was swift to castigate presumption and pretence. Dissentients
from his teaching there were and must be many, for the sanguine revolt
from the cheerless creed of man’s helplessness and Nature’s indifference,
but on all hands he must be acknowledged as a force making for
rectitude that powerfully affected the time in which he lived and that
must far into the future stimulate the thoughts of man.

To discuss Maudsley’s contributions to the physiology and pathology

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202 THE FIRST MAUDSLEY LECTURE, [July,

Journal of Mental Science, and I am confident he will rise from their
perusal satisfied that asylum medical officers have not lagged behind
their profession generally, but have, in proportion to their number, and
having regard to the arduous and time-absorbing routine duties
imposed on them, produced more than their fair quota of sound, pains¬
taking, progressive, scientific work. As regards the humane treatment
of the insane, the nature of the asylum provision made for them, the
investigation of their condition—psychical and corporeal—and the
employment of remedies, medical and moral, for their relief, this country
has nothing to fear from comparison with any other. In every march
forward she has led the van. We are exhorted to look with envy at the
spacious and well-appointed research laboratories attached to some
asylums in Germany, and no doubt in that direction we have been
somewhat distanced by developments in Germany and the United
States, but it should be borne in mind that the first asylum research
laboratory in Europe—small and humble it was, but still a research
laboratory, in which experiments of high and permanent value were
conducted—was established in connection with an asylum in England
more than fifty years ago. Our Scottish asylums have been co-operating
in laboratory work for thirty years, and in several asylums in England
and Wales well-equipped laboratories exist which, now that the war is
over, may be expected to yield a rich harvest.

No doubt in our department changes and reforms are necessary, but
we have been the first to acknowledge it and to press for action. Greater
freedom is needed in meeting the manifold requirements of a protean
disease. Some archaic legal fetters should be struck off, the medical
staff in some of our large asylums should be reinforced and more
liberally remunerated, and, above all, facilities should be afforded for
the early treatment of cases of mental disorder, incipient in character
or of recent origin. But the necessity for early treatment under such
circumstances, the advantage of which has been so conspicuously
demonstrated in the psycho-neuroses of the war, is no new discovery.
You can scarcely open any asylum report for the last fifty years without
finding in it expressions of regret that the patients admitted have not
been more promptly dealt with, and statistical evidence that the
prospect of recovery is in the inverse ratio of the duration of the
insanity prior to removal to the asylum. There can be no question
that the legal formalities connected with asylum treatment, intended
for the protection of the liberty of the subject, have led to some
increase of insanity, or rather accumulation of lunatics. There has
been a natural shrinking from certification, magisterial inspection and
registration as a lunatic or person of unsound mind, and from all the
vexatious limitations that attend detention in an asylum, with the
stigma that it is supposed to leave behind it, and so the evil day has been

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203

in many cases postponed as long as possible; the golden opportunity
has been allowed to slip past unimproved, and what might have been a
transitory illness has been converted into a permanent infirmity.

It was in the hope of avoiding such calamities, and of furnishing
opportunities for the early treatment of cases of acute and recent
mental disorder, while at the same time promoting pathological investi¬
gations and the education of medical students and medical practitioners
in psychology, that Maudsley generously supplied the funds for the
hospital which now stands on Denmark Hill, admirably equipped, and
happily under the sagacious tutelage of Sir Frederick Mott. It was in
1907 that the scheme occurred to him, but long before that the want
of such an institution had been felt and insisted on, and I hope I shall
not be regarded as egotistical if, in order to show that we have not been
as blind and sluggish as is alleged, I quote a passage from the Presi¬
dential address which I delivered to the Medical Society of London in
October, 1895 : “For my own part,” I said, “my hopes are centred in
the establishment in or near London of one or more, not asylums, but
genuine hospitals for mental disease. These hospitals would be
organised like ordinary general hospitals, would have a staff of visiting
and assistant physicians, and of consulting surgeons, and specialists in
diseases of the eye and ear and in those peculiar to women, and of
resident medical officers and clinical clerks. Attached to them there
would be an out-patients’ department and a school of medical psy¬
chology with laboratories and museums, in which systematic investiga¬
tion, teaching and demonstration would be carried on. A few such
hospitals—not merely ‘ monasteries for the mad ’ or convenient shoots
for human rubbish, but real mental hospitals—would exercise at once a
salutary and invigorating effect on the medico-psychological specialty
and bring it back into closer correspondence with the medical profession
as a whole.”

That vision has in part materialised in the Maudsley Hospital, and
the Maudsley Hospital has set an example which will be followed under
the more liberal and elastic lunacy law dispensation which is undoubtedly
in store for us. Hospitals like it will spring up in our large towns, and
pyschiatric clinics will be established in connection with our general
hospitals, where sufferers from mild and larval insanity may receive
skilled treatment in conjunction with patients suffering from purely
nervous affections without incurring the odium of having been in an
asylum. There will be an extension of the out-patient department in
our public asylums and a perfecting of their clinical apparatus, for it is
in them, however successful early hospital treatment may be, that an
enormous majority of the insane will still be lodged and treated.

That early treatment will be successful in intercepting some part of
the stream of the mentally deranged that now flows on so copiously to

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THE FIRST MAUDSLEY LECTURE,

[July,

our asylums cannot be doubted, but exaggerated notions of the benefits
that will acrue from it should not be entertained. The main part of the
stream setting towards asylums consists of congenital idiots and
imbeciles, of general paralytics and chronic epileptics, of confirmed
cases of dementia praecox or paranoia, and of patients labouring under
organic and senile dementia, for whom treatment, early or late, will be
of little avail, and there must always be included in that stream a
certain proportion of recent and acute cases in which dangerous pro¬
pensities render immediate admission to an asylum necessary. Already
too recent and acute mental disorders occurring in persons belonging to
the upper and middle ranks have had the benefit of early treatment
and highly skilled advice by specialist physicians, while in all ranks
such disorders have been and are successfully grappled with to some
extent by the capable general practitioner, who nowadays knows
enough of insanity not to be afraid to touch it, and who in the near
future, it is to be hoped, will be so educated as to be able to deal with it
secutidum artem. Altogether the relief afforded by early treatment to
the pressure on our asylums will not be as great as has perhaps been
anticipated. The special mental hospitals, psychiatric clinics and
mental nursing homes that come into being under the new regime will
be auxiliary to our asylums, but they can in no degree supersede them,
and it would be a misfortune if they derogated in any way from the
reputation of our asylums as curative institutions. Our asylums must
become hospitals more and more, and more and more there must be
enlisted in their service men of high professional and scientific attain¬
ments. There will always be scope in them for the exercise of the
finest qualities of head and heart, of expert discernment, and of the
healing art, and for experimental inquiry as interesting and promising
as that pursued in psychiatric laboratories. Abundance of fresh
material is ever pouring into them, and there is, unhappily, piled up in
them a huge heap of human debris that will reward sifting over from time
to time. Nothing in my official experience has struck me more than the
way in which cases of insanity of long standing and labelled “ chronic ”
have unexpectedly recovered. And apart from any prospect of
recovery, chronic cases of insanity are deserving of scientific attention
and ministration. “ It is not beneath the dignity of a medical man,”
to quote the words of Macaulay, “ to contrive an improved garden
chair for a valetudinarian, to devise some new way of rendering his
medicine more palatable, to invent repasts which he might enjoy,
and pillows on which he might sleep more soundly: and this though
there might not be the smallest hope that the mind of the poor invalid
would ever rise to the contemplation of the ideal beautiful and the
ideal good.”

With the view of insuring that our asylums shall, to the utmost.

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fulfil their diverse functions, it is proposed that henceforth those
holding in them the higher medical posts should possess a diploma in
psychological medicine representing a curriculum of special studies
and an examination thereon. The proposal has much to recommend it,
but I confess I hope it will not be too rigidly interpreted. In general
medicine the asylum medical officer cannot be too proficient, and in
the anatomy, physiology, and pathology of the nervous system he
must have more than the current modicum of knowledge, but as regards
psychiatry in the technical sense I am not quite sure that any great
length of time should be devoted to its academic study outside the
asylum. Of course a general acquaintance with its terms and methods
is desirable, but everyone, lay or medical, acquires some acquaintance
with psychology in his passage through life, and it is in the wards of
the asylum, in the school of experience, that a man must pick up
his practical psychiatry. In the treatment of insanity—in asylums at
any rate—it is the physical conditions underlying the disease and its
corporeal concomitants that should receive primary attention, and any
man endowed with nous and sympathy, the universal solvent, will soon
in his practice acquire a competent acquaintance with mental operations
in their normal and abnormal manifestations. I can conceive of a man
learned in all the wisdom of the psychologians who would be a less
successful asylum medical officer than one with quick insight, whole¬
some imagination and vivid sympathy who altogether ignored Freud
and Hegel. There is a tactus eruditus in handling the morbid mind
that only personal practice can confer. Laboratory methods, as Sir
James Mackenzie has pointed out in reference to bodily disease, in¬
valuable as they are in their proper place, can never, in clinical medicine,
supplant the use of the unaided but trained senses, and may even lead
astray, and so in mental medicine psycho-analytical procedures in their
more intricate applications, interesting and suggestive as they are, can
never, I believe, yield that all-round information and pilotage which
methods of observation, long in use, can, when diligently employed,
supply, and may even involve the oversight of significant facts.

That the adoption in our asylums of every new means of alleviation
and cure which modern science suggests, and in our mental hospitals
and psychiatric clinics of prompt and efficient treatment in early cases
of mental trouble, will have eminently beneficial results cannot be
questioned, but it is, as I have hinted, to neither of these that we must
look for a material reduction in the load of lunacy under which we
groan. In order to secure that we must apply ourselves to the con¬
ditions out of which lunacy grows, and by the curtailment or removal
of these prevent its occurrence.

The recently published report upon the physical examination of men
of military age by National Service Medical Boards during the last year

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of the war presents us with what the Committee themselves describe as
“ ugly facts,” revealing the altogether unexpected extent of the inroads
upon the health and physique of our manhood which the progress of
civilisation in the nineteenth century has brought in its train. Of the
2,425,184 men examined only 871,769, or 36 per cent., were placed in
Grade 1, corresponding with a normal and very moderate standard of
health and strength for their age, while 1,553,415, or 64 per cent., were
classed in the three lower grades, corresponding with different degrees
of physical shortcoming or defect down to permanent unfitness.

The causes of unfitness enumerated in the report, which range from
poor physique and hammer-toe up to advanced tuberculosis and valvular
heart disease, include insanity and mental defect, but afford no in¬
dication of the prevalence of these in the adult population. The
certificated insane and the recognised mentally defective were, of
course, excluded from the purview of the report, and it is notorious
that considerable numbers of lunatics and imbeciles did pass into the
army undetected. Among the volunteers who flocked to the colours in
the enthusiasm of the early days of the war were many men of unsound
mind who slipped through the then cursory examination, some of whom
“foremost fighting fell,” and many of whom have been sent back to find
their ultimate destination in our asylums; and amongst the men who
passed through the stricter scrutiny established under the Army Service
Acts were many who laboured under disabling mental deficiency. The
examination of the National Service Medical Boards was essentially
physical, and practically no mental tests were applied except where
signs of mental weakness were ostensible, and then the tests consisted
in ascertaining what standard at school had been reached and what
wages had been earned, or by setting a simple sum in arithmetic. I
believe that many mentally deficient lads of fair physique, able to do
everything directed by the doctor, were graded 1, until there came a
letter of expostulation from a father or a belated medical certificate
relating facts necessitating rejection.

Had an examination been held into the mental condition of the men
coming before the National Service Medical Boards, at all comparable in
thoroughness and minuteness with that instituted into their physical
condition, and had that examination been conducted by experts, it
would, I am confident, have shown an amount of mental unfitness in
our adult male population—that is to say, in the sanest section of our
community—that would be startling, and would corroborate the finding
of the Ministry of National Service Committee that a grave emergency
exists. Were a psycho-census of the whole people practicable we should
undoubtedly have brought to light in all classes of society an unsurmised
amount of mental deficiency or disorder of one kind or another, and a
wide diffusion of that neurotic temperament that is the soil in which

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the neuroses and pyschoses alike grow. Our mental grade x in such a
census, including average intelligence, the absence of minor mental
defects and general fitness to meet the obligations of life, would be
small and select, and the other grades, corresponding with partial fitness
only, would be made up of heterogeneous masses of mental inefficiency
very unequally distributed in different areas of the country and industrial
centres.

We need not, however, wait for any psycho-census before insisting on
measures being taken for the mental betterment of our people. The
physical returns already before us are sufficient to warrant an immediate
resort to these. Even from the returns of stature alone we might infer,
having regard to the co-relation between height and mental ability, that
there is some general deterioration of mental energy, and the lists of
the causes for which men were rejected or low-graded reveal a multi¬
plicity of morbid physical conditions with which mental disability is
associated or on which it will become engrafted. It is impossible to
regard either the standards of height or of health as satisfactory, and we
may well be surprised, to quote the words of the committee, “ that with
human material of such physique it was found possible to create the
armies which overthrew the Germans and proved invincible in every
theatre of the war.” But the spirit of the race which made that possible
deserves that no efforts should be spared to ameliorate the conditions
which have brought about such deplorable effects upon its health and
physique.

One of the compensations we have for the war, with all its horrors
and anguish, is the discovery of our imperfections and of the risks we
have been running, the realisation of the urgent need of sanitary reform,
and the demonstration—the absolute demonstration—as set forth in
Sir John Goodwin’s recent Chadwick Lectures, of the infallible success
of sanitary precautions scientifically employed. We are awake at last,
and under the Ministry of Health, with its medical head, prompt steps
will be taken for the better housing of our people, with the re-con¬
stitution of family life that that will make possible, for their better and
unadulterated feeding, and for their physical training and protection
against over-fatigue, and for the restriction of the ravages of pre¬
ventable disease, and especially of venereal disease, which will all in
course of time be reflected in improvement in their mental vigour and
in their immunisation from certain forms of mental disease. These are
comprehensive hygienic measures of the need of which every member of
our department is profoundly convinced, and in the carrying out of
which they will all in their own sphere zealously co-operate ; but there
are other hygienic measures of a less material but still momentous
nature with which they are even more closely concerned, and on which
the founder of this Lectureship persistently dwelt. “ The prevention

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of insanity when possible,” wrote Maudsley, “ is a better thing than its
cure, which is often impossible.” And the two principal ways for its
prevention he laid down are to hinder its propagation from generation
to generation, and to employ that training and culture which is best
fitted to repress and suppress its germ in one who is predisposed to it.
Eugenics and education: these are the two great safeguards against
mental degeneration, disease, and decay.

An early eugenist, even before Galton invented the word, Maudsley
strongly advocated the main principles of the science. “ Were it the
rule,” he said, “ in the marriage mart, as in the horse mart, to require a
warranty of soundness, either many marriages would not take place
which now take place, or many actions for breach of warranty would
lie.” “ In the breeding of animals,” he said, “ we should unhesitatingly
discard stock wanting in the qualities which are the best characteristics
of the species. But mental balance and integrity is the highest attribute
of man, therefore all manifesting any lack of it should be for breeding
purposes discarded.” But to this sweeping generalisation he did not
consistently adhere. A believer in the transmission of acquired habits,
and holding that mankind is indebted for much of its progress to
genius, which has almost invariably emerged in families in which there
is a predisposition to insanity, he fell into what we should now regard
as grave error. “To forbid the marriage of a person sprung from an
insanely disposed family,” he said, “ might be to deprive the world of
singular genius or talent, and so be an irreparable injury to the race of
men. Let it be supposed that a person will have children, one or more
of whom will go mad ; it might still happen that the world would gain
more by one of the children who did not go mad than it would lose by
those who did. In that case, would not this marriage, grievous as its
consequences might be to individuals, be amply justified by the good
done to the race ? Nature does not take much account of the individual
or his sufferings; it is singularly lavish in the production and destruc¬
tion of life. Of all the multitude of living germs produced, but an
infinitesimal proportion reaches maturity. If, then, one man of genius
were produced at the cost of one thousand or fifty thousand insane
persons, the result might be a compensation for the terrible cost.”

But the cost, we will now say, would be a good deal too high. In
the case assumed by Maudsley, the production of the mad folks would
be certain, but the appearance of the genius would be problematical;
genius is a rare commodity, and to encourage the marriage of persons
strongly predisposed to insanity on the off-chance of getting one genius
out of fifty thousand lunatics would be an exceedingly rash speculation.
The destruction of superfluous life by Nature takes place for the most
part at an early stage of existence. It is the living germs that are
sacrificed, and that sacrifice goes on abundantly in human beings; but

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lunatics are matured forms, and to sacrifice thousands of them to
lunacy in order to secure even a first-class genius would be ruinous.

Apart from this bit of homage to genius, Maudsley soundly enumerates
eugenic principles. He attaches primary importance to the insane
diathesis or an inborn tendency to emotivity which has played so
conspicuous a part in our war psychoses, he distinguishes the several
varieties of the neuroses which differ in degree and in liability to
herditary transmission, the transformations which they undergo in
passing from one generation to another, and their tendency to reappear
after skipping a generation, and he does all this with a charm of style
and a wealth of metaphor that make his teaching captivating and
impressive.

Since Maudsley’s time eugenics have advanced, and it is possible
now to speak positively on points which he left indefinite, but there is
still infinitely much to be done before a trustworthy code for practical
guidance can be constructed. It is still very often a perplexing problem
to know what to allow or forbid in the marriage mart. But the most
valuable contributions to our knowledge of eugenics in human relations
have come from our lunatic asylums and from the study of inebriates
and criminals, and it is to our lunatic asylums that we must look for
further guidance, now urgently required.

As regards mental deficiency, thanks to the labours of the Royal
Commission and to subsequent legislation, there has been reached
some popular recognition of the risks run and the restrictions and
segregation necessary, but beyond that all is licence and prohibition is
unknown. In the cultivated classes it is rarely that persons complating
union seek medical advice, and the proletariat marry and are given in
marriage without a thought of their physical or mental fitness for
parentage. During the war there has been much precipitate and
indiscriminate matrimony of a very short-sighted description, and
altogether it would be Utopian to hope for any speedy diminution of
insanity due to increased eugenic wisdom. But the eugenic propaganda
should be more active than ever, and the public mind should be
disabused of the notion that the doctors are the uncompromising
opponents of marriage wherever any tendency to insanity exists on
either side. It is theirs to weigh probabilities, and as often to abolish
unnecessary apprehensions as to warn against prospective evils. I
daresay it has happened to many of us to be consulted in fear and
trembling by the son or daughter of a general paralytic, born long
before the infection leading up to that disease was contracted, who
would live for years haunted by misgivings but for the assurance which
the doctor is able to give.'

As regards education in connection with the prevention of insanity,
Maudsley took a broad and judicious view. “There are not many

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natures predisposed to insanity,” he said, “ but might be saved from it
were they placed in their earliest days in exactly those circumstances
and subjected to exactly that training most fitted to counteract the
innate infirmity.” And we may go further than that and affirm that
there are not many natures, whether predisposed to insanity or not,
that may not be fortified by genuine education against the attacks of
those malign agencies that are productive of mental disease, and that
are encountered by all men and women in their journeying through
life. All high-grade alloy steels owe their strength and shock-resisting
properties to scientific heat treatment, and so high-grade brains should
owe their tensile strength and shock-resisting power to the scientific
educational tempering they have undergone.

But scientific educational tempering which will brace the brain and
steady the mind and prove protective against adverse influences is yet
to come. Instruction we have had on the large scale, education to a
limited extent, and while instruction has conferred upon the country
enormous benefits, it has also been responsible for some disastrous
consequences where it has over-strained immature feeble and under¬
nourished brains, or has tended, under hare-brained teachers, to
unsettle these fundamental tenets of morality on which mental and
social stability depend. The seeds of insanity have sometimes been
sown in the school, and its first sproutings have taken place there
unnoticed. “ The loom of youth ” has left nasty flaws and introduced
distorted patterns into the fabrics it has woven and splendid opportuni¬
ties of promoting mental hygiene in our gymnasia have been wasted,
simply because our ruling educational authorities have in their self-
sufficiency ignored psychology and cerebral physiology. We are, I
think, becoming alive to that now. The attention bestowed on the
bodily health of the children since the appointment of school medical
officers has conduced to their mental welfare, and the weeding out of
the feeble-minded has led to the recognition of different degrees of
educability in those who are not technically defective.

But we are just entering on a new era in education and again we
have to thank the war for a drastic change. The new Education Act
has secured for this country, I believe, educational machinery superior
to that of any nation in the world, and it remains for us to put that
machinery to a right use. It has become obligatory to provide not only
a sound elementary or preparatory education for all, but to follow that
up by a further course, the type and extent of which, whether seconday,
technical or university, will be determined, not by social standing or
economic conditions, but in the first instance by the outlook and fore¬
thought of the parents, and in the second place by the ability and
inclinations of the students themselves. Our educational activities are
■to be extended both upwards and downwards, and it is to be hoped

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that in their every stage they will be aided by medical and psycho¬
logical knowledge and experience.

In the nursery schools which are to be established some modifi¬
cations of the methods of Dr. Montessori—a distinguished member
of our specialty, whose system is founded on the work of another of our
confreres, Seguin—will certainly be adopted, and will help on infantile
mental evolution on right lines. In our elementary and secondary
schools expert assistance will have to be sought in adapting the
curriculum to brain growth, and in devising the best means of educing
the inborn capacities and faculties in different groups of boys and girls
at different ages, and in performing a duty in which schoolmasters and
teachers now lamentably fail and for which they are perhaps incom¬
petent, and that is to advise on the course of life and occupation for
which the boy or girl leaving school is best suited by talent, attain¬
ments and predilection, and in which he or she will find most satis¬
faction and success, thus avoiding the danger to mental equilibrium
which an uncongenial like-work entails. In schools of all ranks the
health ideal must be set up, dislodging the old fetish of book learning
with contempt for this vile body, as it used to be called, and in all, as
in the home circle, there must be initiation into the mysteries of life
and the inculcation of sound rules of wholesome living.

In order that education may be made fully effective in the prevention of
insanity and of its neurasthenic and hysterical harbingers much study
of the growing mind is still necessary, and that must be undertaken by
psychological experts, who will no doubt employ psycho-analysis—but
psycho-analysis of our old English type, chaste and approved, with no
admixture of German frightfulness, and in constant conjunction with
neuro-physiology. Much light has been thrown on the part which
education in its widest sense may play in the prevention of insanity,
and on the dangers that attend the lack of it—that is to say, the lack
of trained disciplinary control of the higher over the lower centres in
the nervous system by the psycho-neuroses which have arisen out of
the war; and some light is, I believe, thrown by these on the
mechanism of the brain and on its functional habits. Particularly
interesting in this respect have been those rapid transitions from states
of grave mental disorder and incapacity to restored power and normality
which have been of such frequent occurrence, which have, more than
any other mental war phenomena, interested the public, and which have,
of course, corresponded with sudden brain changes.

Now sudden brain changes are no new things. They have been
brought into prominence by the war, but they have occurred from time
immemorial, and, just as has been the case during the war, many of
the most striking instances recorded in the past have been in con¬
nection with speech and phonation. Herodotus tells us of a son of

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THE FIRST MAUDSLEY LECTURE,

[July,

Croesus who had never been known to speak, but who, at the siege of
Sardis, was so overcome with astonishment at seeing the King, his
father, in danger of being slain by a Persian soldier, that he exclaimed
aloud, “ Oh, man, kill not Croesus ! ” This was his first articulation,
but thereafter he retained his faculty of speech as long as he lived.
Dr. Wigan, the author of The Duality of the Mind , had a patient
eight years old, sound in intellect but perfectly dumb, and whose family
had abandoned all hope of curing him, who, seeing his father fall
overboard from a boat in the Thames, called out aloud, “Oh, save
him, save him! ” and from that moment spoke with almost as much
ease as his brothers. The late Dr. Charlton Bastian was consulted
about a boy—the son of a leading barrister—who had fits in infancy,
and who, when five years old, had not spoken a word. Two eminent
physicians were consulted about his dumbness but could not help him,
but before the end of another twelve months, on the occasion of an
accident to one of his favourite toys, he suddenly exclained, “ What a
pity ! ’’ The same words could not be repeated, nor were others spoken
for two weeks, but thereafter he began to talk and soon became
exceedingly loquacious.

In cases like these there has been, we may presume, an arrest in
cerebral adjustment in one of its compartments. The age at which
articulate speech is acquired, or at which the receptive and motor
neurons concerned in it establish communication, varies considerably
in different individuals, and in cases such as those just mentioned had
been from some cause indefinitely postponed. But a powerful emotional
impulse, which is always of higher tension than a volition, ultimately
forced its way through the prepared, but hitherto untrodden, pathway,
and brought into relation those centres in which had been accumu¬
lated the memories of vocal sounds and those in which had been co¬
ordinated the complex movements of articulation. The channel, once
thus opened up, afterwards remained pervious.

But much more frequent than postponed is interrupted functioning
in certain cerebral tracts, and of that we have many different kinds, all
of which have been copiously represented during and since the war.
We have had not only mutism, but blindness, deafness, paralysis, con¬
tractures, amnesia and other mental derangements of instantaneous
incursion and sometimes capable of instantaneous cure.

Of the war neuroses, due to shell-shock—the terra is objected to, but
I use it as short and convenient and now of pretty general acceptance
—of the war-neuroses due to shell-shock, those in which there has been
severe concussion or commotion cannot, of course, be terminated
abruptly except in death. In such cases ending fatally there have been
found minute scattered punctiform haemorrhages into the periadventitial
sheaths and substance of the brain similar to those seen in gas-poisoning,

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213

but in cases in which the concussion, actual or aerial, has been
less violent, and in which recovery has taken place, there has been
what might be called bruising of the delicate brain tissues. Of all
the lessons in neurology taught by the war there has been none more
striking than that showing the tendency to natural recovery in nerves
which have been concussed, compressed, lacerated, and even divided,
their recovery being sometimes delayed as long as ten or twelve weeks
after the injury. “ After a time,” says Dr. Macdonald, “ regeneration
commences in the lower end of the proximal segment, and new axon
cylinders grow down to and beyond the point of section. In from four
to six weeks there will be bundles of new axis cylinders at this point,
and if they are firmly tapped with the finger the patient will experience
tingling, or ‘pins and needles,’ in the skin over the dorsum of the
foot. If the new axis cylinders succeed in growing down the trunk, or
if the latter has only been contused and has preserved its anatomical
continuity, then, pari passu with the growth of the axis cylinder, there
occurs a downward extension of the distal tingling on percussion.”

Now if similar recuperative changes occur in the neurons, axons,
dendrites or nerve-fibres of the brain which has been subjected to
contusion or compression, we can understand how gradual, although
perhaps long-delayed, resumption of cerebral function takes place where
that has been suspended more or less by shell-shock or other accident,
as in cases of anergic stupor. Under such circumstances sudden recovery
is not to be expected, either through reparative processes in injured parts
or by transference of function to intact areas, but the state of matters is
very different where there has been no coarse change in the cerebral
mechanism, but only that subtle interference with activity which we
call functional.

It is in cases of shell-shock where the physical injury has been slight,
or in cases where there has been no physical injury but merely strain
and stress, fatigue, or violent emotional perturbation, that there is
interruption in cerebral communication amenable to the immediate
re-establishment of continuity. It is in cases where psychogenesis has
been at work that sudden brain changes are most often observed, and
the psychogenetic conditions in such cases according to a certain school
are ascribed to conflicts between the standards of civilisation and a
body of imperfectly controlled and explosive forces in the subconscious
mind, the most common conflict being that between a sense of duty
and the instinct of self-preservation, immediate or deferred. We are
told that the war let loose horribly cruel, sadistic murderous impulses
which had been kept chained down during peace, and that is—as regards
our men, at any rate—I would say, a gross libel and a cruel insult to
those of us who have graves in France and Flanders to tend. As well
say that the operating surgeon is stirred by a latent taste for butchery.

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THE FIRST MAUDSLEY LECTURE,

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No doubt in the heat of battle the combative instinct and the instinct
of pursuit asserted themselves; no doubt now and again a man may
have given way to the lust of cruelty; but throughout the war I am
confident the mass of our men, under the most harrowing and revolting
circumstances, were animated and sustained by worthy motives and not
by subterranean devilry. Their heroism, their endurance, their help¬
fulness in the field, their unaffected stories, their merry jests, the letters
they wrote home, the poems they composed, prove this incontestably.
Even the bayonet exercise they went through, which is singled out as
pure savagery, was engaged in more, I believe, as a trial of skill than
with a blood-thirsty intent. The herd-instinct of which we hear so
much may have helped to hold them together and impose restraint, but
it was patriotism pure and simple, and a sense of right and duty that
enabled them to accommodate themselves to the new assemblage of
strange and horribly trying circumstances in which they found themselves.
Our men went over the top, or suffered long-drawn-out misery in the
trenches, in no spirit of wanton aggression and brutality, but for self-
defence, for the protection of those united to them by family affection,
by friendly association, patriotic sentiment, or for righteous conviction.
The flame of modern knight-errantry was lambent amongst them.

That fear, or rather the fight against fear, and the inhibition of its
expression, have been largely accountable for our war psycho-neuroses
is indubitable, but that in no way impugns the courage of our troops,
for it is to be remembered that although the number of cases of psycho¬
neuroses has been large, the proportion of these to the number of men
serving has been exceedingly small, and that in almost all the cases
of psycho-neurosis thus originating there has been evidence of strong
psychopathic tendencies having existed before the war, or of that
neurotic temperament which corresponds with high susceptibility of
the higher nerve centres and diminished control of the higher over the
lower centres. The trend of modern civilisation seems to have been
to an extension of the dominion of man’s will in the higher or in¬
tellectual sphere, but to a reduction of its sway over lower corporeal
levels. North-American Indians and negroes have a control over the
reactions of painful and disagreeable stimuli which Europeans do not
possess. They can endure without wincing torture which would cause
in us the most lively manifestations of suffering, and I suppose it is true
that the coloured races engaged in the war have suffered less from
shell-shock than our men. Our great-grandfathers were probably harder
and less sensitive than we are to day. The kind of neuroticism induced
by terror or protracted fear will depend on the direction in which
will-power, owing to inborn disposition, over-indulgence or habit is
weakest. The ascendancy of the will is not exerted along particular
lines as it ought to be, and so subordinate centres break away from

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215

authority and unduly assert themselves. Impulses which should be
disciplined become insurgent, and there is not a conflict but a stampede.
“The private,” says Dr. Head, “develops a conversion hysteria and is
carried from the danger-zone paralysed. The officer becomes the
victim of an anxiety neurosis and commits suicide.” An army medical
officer, writing to the Times , says that “ well-bred horses, like well-bred
men, or shall we say highly organised men, suffer from shell-shock
more than low-bred ones, though the same well-bred horses are in¬
finitely more gallant than their low-bred companions.”

There is a well-known anecdote related of some great general who
read on a tombstone the inscription, “ Here lies one who never knew
fear,” and upon this remarked—“ Then that man can never have snuffed
a candle with his fingers.” The emotion of fear must have been felt
by all who in the war have been exposed to imminent peril to life and
limb, and who have at the same time seen around them wounds, death
and boundless anguish and misery, but in the well-balanced mind the
counteractives have been sufficient to hold the emotion in check. The
terrified soldier, we have been told, is restrained by the thought that if
he runs away he will be shot at dawn, but that is a crude explanation
of the way in which terror has been resisted. The instinct of self-
preservation is assuredly primary and paramount, but even in the lower
animals it may be set aside by love of offspring or a rudimentary sense
of herd obligation, and in man it is subordinate to a multiplicity of
sentiments and ideas, ingrained or fluent, which hold up the hands of
the will to resist its promptings, however insistent these may be.
Martyrology is a chronicle of the triumph of religion over the self¬
saving instinct and heroism is invariably associated with its abnegation.
Even inexcusable superstition is sustaining against it. “ A man has a
mascot,” writes home The Boy with the Guns, “ a charm of little worth
though of great value to him, or a photograph or flower; he loses it
and then loses his life. Such things are always happening. And the
men must have something to believe in, and something tangible to
express their belief—a sign, a symbol, something, a link between them¬
selves and the inexpressible, between themselves and all that they
cannot see or understand but which they feel exists.” But the degree
in which the instinct of self-preservation may be held in check under
terrifying conditions depends on the functional activity for the time
being of the highest cortical centres in the brain. Where these are
vigorous and have been braced by discipline a man can command
himself and retain self-possession throughout the most appalling ordeal,
but where they have been weakened and worn down by long stress, by
the constant expectation of evil, or by bodily debility the bravest may
respond to fear-inspiring impressions with reflex uncontrollability.
Under such circumstances self-preservation may assert itself as

LXVI. 15

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inevitably as the blinking of the eye on a threatened blow. Re¬
membering what our men went through, it is reassuring to know that
in cases of cowardice and desertion no man was condemned to death
who could justifiably plead shell-shock or some mental damage. When
a soldier, in his defence or in mitigation of punishment, urged a sub¬
stantial plea on mental grounds, medical witnesses were called, and the
court-martial was adjourned and a medical board was held. At the
adjourned hearing one or more members of the board were called as
witnesses, and amongst them was always a mental specialist if there
was a suggestion of shell-shock or other kind of mental or nervous
disorder.

The fear factor, as disclosed in many of the war psychoses, has been
simple enough in its operation. A man became possessed by fear, felt
ashamed of it, struggled against it, and concealed it from his com¬
panions, but it gradually increased in stringency as he suffered more
and more from fatigue and hardship, and finally overcame him, ending
in a fit followed by mental confusion and delusions. For practical
purposes is it necessary to proceed further in such a case or to invoke
psycho-analysis ? That the mental breakdown resulted from fear, which
a sense of duty and self-respect and apprehension of ulterior risk were
unable to subdue, is obvious enough. Shall we be much wiser or
better able to help our patient if we trace it back, or pretend to trace
it back, to an unresolved infantile mode of behaviour or to some rela¬
tion between it and unsatisfied sexuality? The conclusion that the
morbid variety of fear represents the discharge of repressed and uncon¬
scious sexual hunger is, we have been told, one of the most securely
established in the whole range of psycho-pathology, upon which my
comment would be—“ So much the worse for psycho-pathology ! ”

Emotional conditions, especially when violent and often repeated,
are extremely potent in precipitating new mental arrangements, and it
is little wonder, therefore, that the profound agitations which our men at
the front have passed through have resulted in disruptions of mental
continuity corresponding with disruptions of physiological continuity
in the brain. “ One thing we may conclude certainly,” said Maudsley;
“of all moral commotions and mental overstrains which cause insanity—
that they do so by straining or breaking the molecular ties of nerve
structure and so injuring or destroying its vital activities.” Prof.
Waller’s recent experiments, following on the lines already laid down
by Fdr£, Tarchanoff, Slicker, Muller, and Peterson, have proved
that large and sudden electric discharges which are independent
of any muscular movement accompany a great many of the
alarms and shocks of life. It was found that when strong and dis¬
agreeable stimuli were used—such as an unexpected loud sound,
an unexpected bum, a disagreeable and pungent smell, or a

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painful thought—while muscular movement of any kind was absent,
marked electrical actions occurred. In a Belgian woman who was told
to think of her native land—she had seen various tragic episodes of
the German occupation—a very strong reaction was evidenced, and it
was always noticed that the most effective ideas were such as were
accompanied by disagreeable or painful emotion. We are, I think,
justified in inferring that it is in such electrical discharges accompanying
the intense and violent emotions evoked by the war that we have the
explanation of many of those sudden losses of function which have so
often followed these emotions. Impinging on the synapses of the
neurons, which play so important a part in psychical processes, and
which are the weak points in the nervous pathways, it may well be that
they have increased their resistance in certain areas to the point of non-
oonductively producing a state analogous to fatigue which, when
excessive, results in changes in the cell substance. The discharges
would be most damaging in the higher and later developed levels of
the nervous system, where the cells’ functions are less solidly organised
than in the lower levels, where they are relatively firm and open to the
nervous currents, and they would be most likely to induce injurious
effects where the neurons are constitutionally less closely compacted
and more unstable. An apt illustrative analogy of what probably takes
place under such circumstances is supplied by Mr. Charles Salmonds.
“We may picture,” he says, “an electric current passing through a
copper rod divided into a large number of segments; if at one end of
the rod the segments are pressed firmly together the current passes
easily; if at the other the segments barely touch one another the
current passes the junctions only with difficulty.” Prof. Waller
observed that different subjects react very differently to different
stimuli, and the same subject in different states of health and at
different hours of the day to identical stimulation; and so we can
understand how the violent emotions of the war have caused sudden
brain blockage in men predisposed to hysteria, neurasthenia, or the
psycho-neuroses, exhausted by strain and stress or worn down by
illness, while they have left men of more equable temperament and in
sound health unscathed.

Recovery from brain blockage and the re-establishment of synaptic
transmission sometimes takes place almost immediately, and, as it were,
spontaneously ; sometimes gradually, in altered environment and under
medical treatment or re-education, and sometimes even after long delay
quite suddenly under an emotional jerk much milder than the original
shock, but, like it, accompanied, no doubt, by an electric discharge,
exciting a change in . the synaptic membrane by which transfer takes
place. The emotions producing brain-blockage are almost invariably
of a painful and startling description ; those removing it are generally

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of a pleasurable complexion. We are all familar with such cases.
Many disabilities have been swept away in the twinkling of an eye by the
announcement that a man would have no more fighting to do. Power
was instantly restored to the paralysed arm of a soldier on receiving an
affectionate letter from his wife. A soldier who had been rendered
deaf and dumb during the fighting in Flanders regained speech and
hearing in a burst of laughter during a humorous sketch at a concert
in his hospital, and another soldier struck dumb in battle was cured on
the spot by being kissed by a young lady visiting at his bedside. The
way in which an emotion may counteract the effect of mental shock
and blockage is very beautifully illustrated by Tennyson :

" Home they brought her warrior dead;

She nor swooned nor uttered cry ;

All her maidens watching said,

‘ She must weep or she will die.’

“Then they praised him soft and low.

Called him worthy to be loved,

Truest friend and noblest foe.

Yet she neither spoke nor moved.

“ Stole a maiden from her place,

Lightly to the warrior stept,

Took a face cloth from his face;

Yet she neither moved nor wept.

“ Rose a nurse of ninety years,

Set his child upon her knee.

Like summer tempest came her tears.

' Sweet my child I live for thee.’ ”

The appropriate affinitive impression for the relief of shock in this
case—an excitation that discharged inhibition—was discovered, not by
any process of psycho-analysis, but by the ripe experience of an old
woman. Similar experiences sometimes surprise us in our asylums. I
remember reporting the case of a young woman (S. W—) who had been
a schoolmistress and who laboured under dementia praecox—or acute
dementia as we then called it. She was depressed, imagining she had
done some great wrong, and markedly stereotypic, remaining fixedly in
any position in which she was placed, and being generally mute. She
was several months under treatment, showing no marked improvement,
when suddenly one evening she shook off her lethargy and became
quite herself, and remained from that moment bright, intelligent and
natural in her conduct. Her quick recovery she herself explained,
saying that it came about as she was being fed with her evening meal
by a new nurse who had just come into the ward. She heard the
nurse tell another nurse that she came from Lincoln, and the mere
mention of Lincoln, where she had herself been born and reared

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called up a flood of happy memories which swept her delusions and
inertia away. The motherland suggestion, as the psycho-analysts
would call it, was obviously the touchstone in this case, but perhaps
the course of baths and tonics to which the patient had been submitted
had prepared the way for its magical effect.

We have all, no doubt, met with instances of this sort in which there
has been sudden relief from brain stasis by an emotional antigen, and
most of us must have had personal experience of the effect of a summation
of voluntary stimuli in procuring significant brain changes at an express
rate. In the lapses of memory which occur during fatigue, illness or
old age, we grope anxiously about for a time for a proper name, and
then it suddenly flashes upon us, the reinforced mind current having
spanned the synaptic gap, just as an electric current of higher poten¬
tiality will spark across an interval that was too wide for a current of
lower potential to leap.

In connection with sleep sudden brain changes are noticeable. Its
incursion is ordinarily gradual. The senses are closed, will-power is
let slip, and fancy, free from control, sports for a little discursively and
then subsides; but sometimes, as in extreme fatigue, sleep comes
instantaneously with a snap. There is, as it were, brain stasis in sleep
but no general blockage, and on waking the stasis gradually gives way
before the stream of returning consciousness, first trickling and then
flowing freely; but the stream may come with a gush, and then in¬
stantaneous awaking occurs. Dreams are, of course, replete with
sudden variations, and Dr. Hughlings Jackson suggested that certain
absurd and persistent delusions are fixations of grotesque fancies and
dreams in which a morbid change in the brain has happened suddenly
and increased suddenly during sleep. The fixation of the grotesque
fancies or ideas gives rise to an imperative and fixed idea, and
Hughlings Jackson thus accounted for these quasi-parasitic states or
delusions in cases where general mental power is but little lessened.

Deeply interesting studies of sudden brain changes may be made in
connection with what is known in religion as conversion, of which I
must only speak here with great deference and reserve. On its theological
aspects I must not touch beyond saying that it is by great multitudes
of people regarded as a direct spiritual influx and outpouring of divine
grace—a sort of celestial telepathy—and there can be no doubt that it
has, on the large scale, meant an altered attitude towards life and a
favourable change in disposition, character and conduct, sometimes
transitory but often enduring. But from the physiological side it is an
inner brain happening with new arrangements of nerve-currents, and
where it has taken place in connection with revivals it has often pre¬
sented many of the features of recovery from shell-shock and anxiety
neuroses, and under such circumstances might be described as soul-

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shock. It is no slow growth, but catastrophic in character. John
Wesley said: “In London I found 652 members of our Society who
were exceedingly clear in their experience and whose testimony I had
no reason to doubt. And every one of these, without a single exception,
has declared that his deliverance from sin was instantaneous—that the
change was wrought in a moment.” In the revival cases certainly, and
in many others just as in our psycho-neuroses cases, the soul-shock has
been brought on by fear, or by fear and the promptings of the instinct
of eternal self-preservation. It has been by appeals to fear that revivalists
have carried out their mission. They have succeeded in inducing in
their more sensitive auditors a state of terror not unlike that experienced
by the more emotional of our soldiers in the perils of the trenches and
the field. Our men have constantly described the battles in which
they took part as “ hell,” and it is by visions of hell conjured up before
them that the ardent votaries of evangelical religion have been plunged
in emotional perturbation. Jonathan Edwards, whom all succeeding
revivalists have imitated, thus horrifically played on the feelings of a
congregation : “ If we should suppose that a person saw himself hanging
over a great pit full of fierce and glowing flames by a thread that he
knew to be very weak, and knew that multitudes who had been in that
position before had fallen and perished, what distress would he be in.
The unconverted belong to the devil, and he is ready to seize them the
moment God permits. God is more angry with many of you now than
he is with many in the flames of hell. Some of you will within a year re¬
member this discourse in hell. You would have gone to hell last night had
not God held you like a loathsome spider over the flames by a thread.”

We cannot be surprised that exhortations like this, delivered with
superlative earnestness and unction, repeated again and again, wrought
up to great excitement a crowd of people often in a state of exhaustion,
for the services went on for hours, sometimes continuously by day and
night. Shouting, singing and groaning were indulged in, and all sorts
of nervous disturbances and even insanity resulted. Let me quote a
description of a revival at Red River in 1800. At the words of an
effective preacher faces were streaming with tears at a pungent sense of
sin, and the cries for mercy were terrible to hear. The floors were
covered with the slain. Services were held for seven days and some¬
times all night. The circulation was affected, and nerves gave way;
many dropped to the ground, cold and still, or with convulsive twitches
or chronic contortions of face and limbs, and at Cover Ridge 3,000
were laid out in rows. The crowd swarmed all night from preacher to
preacher, singing, shouting “ Lost! Lost! ” leaping and bounding
about. As the excitement went on it took the form of jerking,
beginning with the head; with others it became barking, or the holy-
laugh, as it was called. They saw visions and dreamed dreams.

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The transports of these revivalists were, for the most part, short-lived,
and passed away, leaving only nervous exhaustion behind, but in a
large number of instances they were followed by anxiety neuroses and
psycho-neuroses of a pronounced type. There was prolonged melan¬
cholia, with delusions, headaches, sleeplessness, hallucinations—such
as voices summoning to repentance and visions of the Day of Judgment
—palpitations, sweatings, indigestion, vomiting, and nervous tremors
and convulsions, and it was from this state of engrossment of the mind
by one system of ideas that conversion was the escape. By persuasions
by the minister or evangelist, by suggestions of friends, by some
emotional appeal in the singing of a hymn, or by some trivial and
apparently irrelevant incidents, as the reading of a text, conversion
came in a flash, and not only was mental tranquillity restored, but a
state of complete happiness was reached. A transformation took place
which could not be clearly set forth in words, but which was vaguely
described by those who had undergone it as “ Heaven upon earth,”
“a mighty presence,” “a sense of newness,” “a great surrender,”
“ assurance of salvation,” “ a glorious light,” “a wave of the spirit,” and
so on. In such cases the translation from one order of thought and
feeling to another that occurs in so many young people brought up in
evangelical circles, as a normal phase of adolescence and a growth into
a larger spiritual life, takes place momentarily. At the summons of
some particular event or word a feeling is aroused that spreads itself
like wild-fire over the whole field of consciousness and imparts a
colouring to all elements included in it. This religiosity per saltern
connotes a sudden change of current in the association centres of the
brain. The old system is changed, beaten tracks are deserted, and new
communications are opened up. In a violently excited state of emotion
pressure in the brain-cell or psycho-active matter is increased just as a
stronger current is yielded by a heated electric cell. And this gives
rise to movement without and within. There is muscular restlessness,
associations are no longer regulated by established canons, overflow
takes place, and after an inundation, more or less wide-spread—the
confused and hallucination period—fresh channels are hollowed out
and an entirely new system of canalisation is established. This may be
permanently maintained, or it may be relinquished, in a return to the
old system.

The Eleusinian mysteries seem to have had something in common
with modern revivals. They aimed at counteracting the passions of
ordinary life by the abiding remembrance of an appeal to terror and
pathos, and so profound was their influence that it was said of some
who have gone through them that they were never seen to smile
afterwards.

Many who have never undergone religious conviction are aware of

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secular experiences of a somewhat similar type, critical moments in
their lives—often during adolescence—when quite suddenly and without
warning new life streamed in on them, as if from without. A course
of study may have led up to it, a strong emotion may have pre¬
ceded it, or some quite trifling incident may have determined it, but
abruptly and inexplicably the change came, and a sense of strange¬
ness and expansion dawned. There was a jolt, a turn, and the mental
contents were as if kaleidoscopically re-arranged in an order different
from that which had hitherto obtained. A memorable example of this
spiritual new-birth, reached not by gestation but by a regenerative
flash, as it occurred to Carlyle he has himself described: “ Nothing,” he
wrote, “ in Sartor Resartus , is fact, symbolical all, except that of the
incident in the Rue St. Thomas de L’Enfer, which occurred quite
literally to myself in Leith Walk. The incident was as I went
down I could now go straight to the place,” and the incident may
be epitomised as follows: “ Full of such humour and perhaps the
most miserable man in the whole French capital or suburbs
was I one sultry Dog-day after much perambulation toiling along
the dirty little Rue St. Thomas de L’Enfer, when all at once there
arose a thought in me, and I asked myself ‘ What art thou
afraid of?’ and as I so thought there rushed like a stream of
fire over my whole soul, and I shook base fear away from me for
ever. I was strong, of unknown strength ; a spirit, almost a god.
From that great moment of Baphometic Fire baptism I became a
new man,” or, as Carlyle has it, “ I authentically took the devil by the
nose ”—a victorious ending of a protracted conflict.

But besides sudden expansions there are sudden contractions of
brain energy. “ The memory of James Hinton as a boy,” Sir William
Gull has said, “ was quite marvellous. A school fellow of his at
Reading recalls that when the master set six pages of history, Hinton
read it once over and repeated it verbatim. But rushing one day
hurriedly from cricket to his lessons there was a sudden lapse of this
remarkable power, a sense of gone-ness, and it never returned to him.”

I have referred to cases in which sudden recovery from insanity has
taken place, in response to some moving emotion, and we are all
familiar with cases in which sudden recovery and relapse occur under
some periodic physiological law still unexplained, allotropic brain
changes they might be called. But I should like to mention that there are
cases in which sudden recovery supervenes on a physical concussion
or jar. It is easy to understand why physical shock should interrupt
the functions of the brain, but it is not so easy to understand how it
should resuscitate them and restore their balance. Some time ago I
visited a gentleman who had for years laboured under delusions of
persecution, which had become so aggressive as to make him dangerous

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and to necessitate his being placed in an asylum. Two attendants
having arrived at his house to remove him, he rushed upstairs to
escape from them, and jumped from a first-floor window into the street.
When he was picked up it was found that his vertebral column was
broken in the dorsal region, but that he was perfectly clear in mind.
His delusions had vanished, and he was reasonable and collected. He
ultimately died from the effects of his injuries, but he lived some
months, and was lucid to the end. The late Dr. Robert Smith, of the
Durham County Asylum, reported a similar case, that of a woman,
set. 36, labouring under confirmed melancholia, who one day, under
the hallucination that she saw her husband outside, smashed a window-
frame with a brush-handle and jumped through, falling a height of
24 ft. and alighting on a gravel walk. She fractured her,leg and
sustained other injuries, but did not lose consciousness, and recovered
her soundness of mind on the spot. All her depressed delusions left her,
and, in the course of a few weeks, she went home quite well. Sir James
Dundas Grant has given me the notes of the case of a man who was
wounded at Delville Wood on the Somme in July, 1916, by a bit of an
exploding shell. He remembered nothing more until, coming to him¬
self in a train, he found he could hear nothing. He remained deaf until
August, 1917, when one night he had a vivid dream that he was going
through the shell incident again. In the agitation caused by this dream
he fell out of bed and knocked his head on the floor. His mother
hearing the noise, came into the room and asked him what was the
matter. He heard her question and replied, and has been able to hear
perfectly ever since.

One can only speculate as to what went on in the brain in such
cases, but assuming that it was not a psychical shock that proved
curative, it might be suggested that the change was analogous to the
rearrangement of particles and altered electric resistance that takes
place in a coherer when it is tapped. The impact broke down morbid
cohesions in brain elements, permitting unusual conditions, and then
the nerve currents flowed back into their normal channels.

Dr. Feldman has described the case of a woman suffering from
trinitrotoluene poisoning, who illustrated the effects of physical shock
during suspended brain function. She developed delirium quite
suddenly, was restless, and not in her right mind, and then developed
twitchings and became semi-conscious, the jaundice being intense.
The window just over her bed in the Poplar Hospital was broken by
the great explosion in January, 1916, and she sustained a severe shock,
and the remarkable feature of the case was that by the next morning
she had completely recovered consciousness and was quite natural.
On the second day she was much improved, but on the fourth day she
had relapsed into the same condition she was in before the explosion.

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A severe physical shock had, in this case, a very marked effect on the
central nervous system, even during what proved fatal toxaemia.

In recurrent insanity we have, one may suppose, alternating currents,
the brain, in which resistance in the synapses in certain tracts and
centres normally in relation is for a period increased to the point of
blockage, and is then, for another period, relaxed and overcome, and
the alternations often take place quite suddenly. Some years ago I
visited, with the late Dr. Louis Bockhardt, of Manchester, a lady who
suffered from intermittent mania. On one day she was in all respects
lucid, calm, rational, intelligent; on the other she was a different being,
excited, incoherent, mischievous. This sad sequence had gone on for
years when, on one occasion, it was curiously interrupted. The lady,
being a German, attached much importance to the domestic observance
of Christmas, and Christmas Eve, being her good day, she spent happily
with her family. On returning with her nurse to her rooms in the
evening she said to Dr. Bockhardt, “ I mean to eat my Christmas
dinner with my mother at her house to-morrow.” “That is not
possible,” Dr. Bockhardt replied, “ for to-morrow is your bad day.”
“ Yes,” she said, " but I will tell you how I can manage it. I will make
to-day and to-morrow into one day. I shall keep awake all to-night,
and I shall be as well as I am now to-morrow morning.” She kept her
word. She went to bed, remained there quietly the usual time, wide
awake, the nurse sitting up with her, and was calm and collected on
Christmas morning and dined with her mother on that day. She slept
well on Christmas night and awoke the following morning in the state
of mental excitement which had been postponed for twenty-four hours.
In this case the change in the couplings of the nerve centres corre¬
sponding with orderly and disorderly mental action only took place
during the suspension of the influence exerted by the higher nerve
centres over the lower which takes place in sleep, and the patient,
having herself become aware of this, was able by maintaining the
activity of the higher centres to put off for a time the running riot of
the lower ones. She gave an extension of power to inhibition, but she
could not permanently re-establish its authority.

In a moment of bitterness Maudsley once imagined a physician who
had spent his life in ministering to the mind diseased looking back sadly
on his track, recognising the fact that one-half of the diseased beings
he had treated had never got well, and questioning whether he had
done real service to his kind in restoring the other half to reproductive
work. But it was in no such mood that he provided for the Maudsley
Lectureship and Hospital. He must, then, have had faith in the seeds
of time and hope in the future of psychological medicine, and it is, I
feel sure, in such faith and hope that our speciality accepts his gifts and
pursues its mission. The old order changeth everywhere, and the new

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order that is taking its place, in our department at any rate, however
diverse its methods may be, is alive and in earnest. There is no help¬
less folding of the hands, nor shruggings of despair, but strenuous
endeavour and a confident expectation that much may and will be
done to stem the devastating tide of madness and to increase the
number of rescues from its troubled waters.

Proceedings.

The President said it had fallen to his lot to have the honour of presiding at
the First Maudsley Lecture. He thought that any of his hearers who contemplated
the problems of history would always find it difficult to judge whether any special
event, or any particular individual, had had much influence in shaping history.
But in this particular case he thought they would have very little doubt. In the
years immediately following the publication of The Origin of Species there
was a great awakening on the subject of the study of psychological medicine, and
in this regard two names stood out. One of those was the name of Dr. Maudsley,
whom they were now met to honour, and the other was the name of the Lecturer
to-day. (Hear, hear.) He did not intend to speak about Dr. Maudsley at all: that
was the subject of the Lecture. He wished merely to say, in that regard, that this
Lecture was due to his munificence in bequeathing a sum of money for lectures
on the subject of mental disorders and allied sciences. Maudsley’s life was
devoted to the welfare of the insane : posterity was to be benefited by his foresight.
In the early years of the West Riding Asylum, 1871 and onwards, under the care of
the then Dr. Crichton-Browne, there was a galaxy of talent which had an immense
influence upon history. Among the early contributors were David Ferrier,
Herbert Major, T. W. MacDowall, Hughlings Jackson, Clifford Allbutt, W. B.
Carpenter, Lauder Brunton, John Merson; and this was all organised and
arranged by Sir James Crichton-Browne, who was to lecture to this audience
to-day. He thought the connection between that and Dr. Maudsley’s first book,
Physiology and Pathology of Mind, which was published in 1867, was in¬
teresting. He was sure those two events had much to do with the development
of the specialty. He had great pleasure in asking Sir James Crichton-Browne
to deliver his address.

Sir James Crichton-Browne was cordially received and delivered his lecture
with an eloquence which always distinguishes his public utterances. His lecture
was heard with deep interest and many of his striking passages with much
applause.

On its conclusion, the President said the Lecture had been a wonderful one;
beautiful thoughts had been expressed in beautiful language, and in a beautiful
way. And though they knew there could be no merit in eloquence as such, that
there was nothing more than temporary value in a silvery tongue, yet they did
know that when this was coupled with penetrating insight and with clear and lucid
thinking the result was wonderful, and such it had been to-day. He had been
particularly charmed by the note of hopefulness which ran through the Lecture.
He believed Sir James Crichton-Browne began the practice of medicine so long
ago as 1861, and he was President of this Association more than forty years ago.
He had now given a resumt of his work and of his thought, which was full of
hopefulness to those in the specialty; it was an inspiration to them, and he was
sure the audience would wish that Sir James should be cordially thanked for his
Lecture. (Applause.) He had one suggestion to make. He believed it was one
of the conditions attaching to the Lecture that it should be published in the Journal
of Mental Science. That, he did not doubt, would be fulfilled, and in that way it
would appeal to a very much larger number than could be present to hear it. As this
was not now a meeting of the Association, nothing in the way of business could
be done, but he proposed to suggest to the Editors of the Journal that the type
be kept up until there had been an opportunity for the Council of the Association
to come to a decision on that matter. He would like the Lecture to be printed
and circulated in pamphlet form, printed on good paper, and circulated widely, so
that it would reach a much larger circle than the Journal catered for. He had

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the support of the Treasurer and the General Secretary in making the suggestion,
and he hoped it would be carried through. In order to give support to the thanks
he had ventured to express, he asked Sir George Savage to say a few words.

Sir George Savage said the duty which fell to him was a very simple one.
All who had heard the lecture must have appreciated it from beginning to end,
both its matter and the manner of its delivery. The orator who had to speak on
such a subject should refer to the man, to his works, and how he was represented
by his writings, and, most importantly, the way in which he would look upon the
work of to-day. Sir James Crichton-Browne, like the speaker, knew Maudsley for
many years, and they recognised his very strong individuality. He was a member
of the Reform Club, and he himself had many reforming characteristics. The
requirement of him (Sir George), however, on this occasion was not to speak of
Maudsley, but to express the feelings of gratitude entertained by this meeting
towards Sir James Crichton-Browne for having placed so lucidly before his
audience the character of the man and his works. He did not think there was any
man better calculated or more suited to give this oration than Sir James ; it was
the eloquent man discussing the fluent man. Maudsley was not the fluent orator
that Sir James was, but he was polished in his written word, just as Sir James was
polished in speech. He (Sir George) could not help wondering, towards the close
of the lecture, what Maudsley’s feelings would have been in regard to psycho¬
analysis, with what scepticism he would have approached that and the subject of
shell-shock. There was nothing so useful to mankind as prudent unbelief. He
was sure all present would feel that Sir James Crichton-Browne had inaugurated
this oration in a way which was worthy of him.

The vote was carried by acclamation.

Sir James Crichton-Browne (in reply) thanked the President and Sir George
Savage for their kind words. He regarded it as a very honourable compliment,
the greatest that had fallen to his lot, to be asked to deliver this lecture to his
friends and compeers in that department of medicine with which he (the speaker)
had been so long connected. And it was very gratifying to have an old friend like
Dr. Bedford Pierce in the chair, because he stood half-way between the old guard to
which he himself belonged and the new army which had sprung up and was now so
vigorous. Dr. Pierce had shown the wisdom and moderation of the old guard and the
originality and enthusiasm of the younger men who were pressing to the front.
There were some stipulations connected with the lecturer, and one which should
have been imposed in his case was that he should have been compelled to undergo
a course of instruction for the Diploma in Psychological Medicine before being
called upon to deliver. He would then have been better able to adapt himself to
the attitude of younger men with high philosophical and scientific attainments.
He had written the lecture under pressure due to other engagements, but he had
done it con amore, and his pen had run away with him ; hence he had, in the
reading, left out page after page, with the feeling which occurs to all who
have to cut down their own compositions, that he was throwing perhaps
the best of his progeny to the wolves. And those excisions might have been more
painful to his audience than to himself, for they probably interfered with the con¬
secutiveness of the address. But he wished to express his great gratitude for the
patience with which he had been listened to. (Applause.)

Appreciation by the ' Times,' May list, 1920.

Sir James Crichton-Browne, the distinguished alienist, called attention yesterday
to the “ load of lunacy ” under which the nation suffers. We are not sure that
the figures of lunacy, grave as they are, need be taken to indicate an increase in
insanity. There is an idol of the statistician as well as of the market-place;
increase and decrease of percentages require scrutiny before they should arouse
satisfaction or dismay. With insanity, as with other human afflictions, increased
skill in diagnosis, more thorough sifting of the population and the provision of
facilities for treatment discover cases that formerly passed unnoticed. Even at
present the school attendance officer unearths the idiot child, and the fool of the
family is handed over to the county asylum. We may predict with assurance that
when more psychiatric clinics are provided, the provision for out-patient treatment
extended and the legal formalities connected with certification are reformed, the
first result will be an apparent increase in the numbers of the insane. The process

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of prevention will reveal the extent of the evil. Everyone will agree on the need
of more facilities for the study and treatment of insanity. But alteration of the
law regulating the certification of lunatics is sure to arouse suspicion. The
putting away of an inconvenient relative by means of a certificate has been a
favourite theme of playwrights and novelists, and an occasional case in the Law
Courts seems to justify popular dread. Yet there is a strong case for alteration.
The existing Lunacy Act protects the liberty of the subject, but does not provide
sufficient scope for treatment and cure. The early symptoms of mental disorder
often occur before certification is possible. It is during these incipient stages that
skilled attention is most successful and most difficult to obtain. The Professor of
Psychiatry in the University of Edinburgh recently stated in our columns that
Scotland in this respect is more happily placed than England. For more than
fifty years mentally-deranged persons in Scotland have been able to receive
curative treatment in any house or home without being certified to be insane and
without being sent to an asylum. These powers have not been abused, and there
is no reason to suspect that they would be abused in England. At the present
time, indeed, insane patients are often sent by physicians from England to Scotland
to benefit by the more considerate laws. The army authorities during the war
arranged that mentally-disordered soldiers should be received into military mental
hospitals without orders or certificates, and did not send cases to asylums until
mental disability had lasted for nine months and was deemed incurable. Large
numbers of men were received in early stages of mental disease and were cured.
Authority and practical experience combine to recommend the reform of the
Lunacy Law.

The Relation of Infections to Mental Disorders .0 By W. Ford

Robertson, M.D.(Edin.).

Some of you may remember that, four years ago, I inflicted upon you
a paper dealing with almost the same question. It was entitled “ Some
Examples of Neurotoxic Bacterial Action.” Since that time I have
continued, in the Laboratory of the Scottish asylums, the practical
study of bacterial infections on a fairly wide basis, and I believe it is
now possible to define with something approaching exactness the part
which such infections play in the causation of mental disorders, including
insanity. It can now be shown that this part is a very much larger one
than at present is generally believed. The same can, however, be said
with equal truth regarding the relation of infections to common maladies.

It is to be remarked, in the first place, that asylum patients, like other
persons, may suffer from acute and chronic infections which produce
the ordinary results. For example, they are subject to common colds,
influenza, pneumonia, bronchitis, dysentery, and tuberculosis, all of
which are of bacterial origin. There is now, however, solid ground
for the conclusion that bacterial infections have also a special relation
to mental disorders. Nevertheless, there are few bacteria, if indeed
there are any, that can be said to produce insanity as the characteristic
result of their pathogenic action. The special relation is dependent
essentially upon a peculiar vulnerability of the central nervous system

( l ) A paper read at a meeting of the Scottish Division of the Medico-Psycho¬
logical Association, November 21st, 1919.

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in some persons. This, I believe, is a conclusion that must be accepted
by anyone who considers the ascertained facts regarding the incidence
of bacterial infection in the iq e and in the general population, and
the effect of properly directed therapeutic immunisation in both. It is
a view that has been expressed before, and never, in my opinion, better
than it was by Dr. C. C. Easterbrook ( 2 ) in the course of the discussion
on the psychoses of infection and auto-intoxication at the International
Congress of Medicine in 1913. Dr. Easterbrook asked, “ Why did only
a small proportion of feverish patients become delirious ? Why did
only a very small proportion of subjects become mentally affected after
an attack of fever ? Undoubtedly it was the nervous constitution,
temperament, disposition, or mental make-up of the patient that made
all the difference.” In his opinion, “ This was the common underlying
factor in the aetiology of insanity, and explained why only a relatively
small proportion of humanity broke down mentally under the action of
the many traumata or stresses that daily affect mankind, including the
infections and toxaemias. No one became insane without previously
being or becoming neurotic, and the neurotic constitution was mani¬
fested in many ways and from various sources of evidence, and especially
from the disposition, which perhaps it would be possible to express some
day in bio-chemical terms, and so to demonstrate that the neurotic with
abnormal chemical affinity of his neurons became a prey to infections
and toxaemias.” With every word of this pronouncement I agree. If
this position is accepted it is evident that, in order to advance our
knowledge of the pathology and treatment of insanity, we must investi¬
gate not only the exciting causes, but also the predisposing ones.
Neither of these two factors is simple—each is, indeed, extremely com¬
plex. There are many exciting causes apart from bacterial toxic action,
and the predisposing causes are still in many respects obscure and
capable of only imperfect analysis. One very important distinction can,
however, be made between what we are obliged already to regard as
the chief component elements of the predisposing and exciting factors
respectively. It is that while we can do little or nothing to alter the
inherent qualities of the brain, which are largely fixed by heredity, we
can exercise now a very powerful corrective influence upon many of the
common toxic conditions that excite mental disorder. Extensive investi¬
gation in the laboratory has shown that most of these toxic conditions
are bacterial in origin. The invading bacteria can be isolated, and
their injurious action is, to an important extent, capable of being con¬
trolled by therapeutic immunisation. Hence the subject of bacterial
infection has become one of paramount importance in the pathology of
insanity, just as it is now one of paramount importance in the pathology
of common maladies. Evidence of what I attest can be adduced, and
I hope soon to publish it in a systematic and detailed form in a book

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on therapeutic immunisation. It is possible to give here only a brief
summary. Before I come to this, however, I must endeavour to make
clear one or two important points that f .^teems to me must be grasped
by anyone who would understand aright' the relation of infections to
mental disorders. 1

It should be evident that there is a fundamental difference between
the manner in which toxins cause disorder of the mental functions in,
for example, acute confusional insanity and dementia prsecox during its
later stages. The text-books, with one or two exceptions, do not explain
this difference. Their general point of view is that of pure psychology,
and on purely psychological grounds the matter does not permit of a
satisfactory explanation. It can be understood only when the pathology
of insanity is considered from a different standpoint altogether, namely,
that of general pathology. In an article in Green’s Encyclopedia and
Dictionary of Medicine and Surgery, I have endeavoured to show that
the pathology of insanity can be brought into line with general patho¬
logy. To the orthodox psychologist this is impossible. The stumbling-
block is apparently the absurdity, in his opinion, of presuming to regard
mind as merely an expression of the functional activity of the brain,
corresponding to the functional activity of the stomach or kidneys. It
has been laid down by psychologists that “ Brain is not the organ of
mind in the sense in which it is the organ of sensori motor activity,”
and that “ There is no evidence to support the position that mind is a
function of the nerve-fibres and nerve-cells.” On the contrary, it seems
to me that there is no definite evidence of its being anything else;
indeed, the view that mind is an expression of the functional activity of
the brain, or, more strictly, of the association centres, instead of being
absurd, is supported by a mass of anatomical, physiological, and patho¬
logical evidence that the psychologists are either unaware of or are
incapable of interpreting correctly. For my part I am certain of this,
that only by regarding the intellect and emotions as expressions of the
functional activity of the association centres can we ever obtain any
clear and useful view of the pathogenesis of insanity—clear, because it
defines and explains the mode of action of each pathogenetic factor,
and useful because it guides us to important therapeutic ends.

With the object of convincing you of the importance and necessity
of regarding in a particular way all toxic actions that have to do with
the causation of insanity, I must ask you to consider for a moment two
other interpretations of familiar facts. The one has regard to the asso¬
ciation centres as complex reflex mechanisms, and the other concerns
the nature of disease.

Every living thing is the product of two distinct factors—heredity
and environment. Heredity is only a moulding force, varying slightly
in its potentialities in different stocks in the same species. In co-

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operation with environmental forces, it builds up from the germ-cells,
a highly complex organism. The individual thus developed is a vital
reactive mechanism ; every vital phenomenon it is capable of exhibiting
is of the nature of a response to external stimuli. This is true of the
being as a whole, of the separate organs and of each cell composing
the tissues. For example, the functional activity of a glandular organ,
such as the stomach, is purely a response to stimuli from its environ¬
ment, which includes the other organs and tissues of the body. The
same principle applies to the nervous organs, and not only to the
lowest, but to the highest. The brain is a reactive mechanism of
extreme complexity, commonly elaborated to an extraordinary degree
by education. Consciousness we can understand only as a concomitant
of reaction in the associative or psychical centres. When we hear the
ring of the telephone bell and go to the instrument to answer the call,
we perform a series of complex reflex actions induced, firstly, by the
sound of the bell, and secondly, by the representations awakened thereby
in the psychical centres, and with every step of the series of reactions
there flows a stream of consciousness. Normal mental reactions are
strictly conditioned by the integrity of the central nervous mechanism.
If this mechanism is damaged its functional reactions must be abnormal.
The mechanism becomes damaged either by traumatism or as a con¬
sequence of disease. We have to consider the nature of disease.

Disease is essentially a reaction on the part of the living body to an
inimical force that has penetrated its first line of defence, constituted
by the skin and mucous membranes. Pathogenesis is an account of
the defensive struggle, of the forces engaged on either side, and of the
havoc often wrought in the course of the battle. As results of this
struggle and of the exposure of delicate structures to toxic actions,
irreparable injury may be sustained by various organs and tissues, in
consequence of which their functions are afterwards imperfectly per¬
formed and conditions of auto-intoxication are induced. Some tissues
have very little power of self-defence, and their escape from injury
depends upon their relative invulnerability. If a toxin is circulating
in the blood, it will fix itself in any substance with which it has a
chemical affinity. Now there are many toxins, and some of them of
bacterial origin, that have special affinities for nerve-cells. The liability
to be injured by such neurotoxins is, however, not the same in all
nerve-cells. There are wide local and individual differences, dependent
upon congenital and acquired qualities. Special vulnerability to toxins
on the part of the nerve-cells of the association centres in some stocks
appears clearly to be at least one important factor included in hereditary
predisposition to insanity. Two distinct effects upon the association
centres must be recognised. During the height of the toxic action the
metabolic processes occurring in these centres are seriously disturbed ;

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mental reactions correspondingly are disordered and consequently there
is confusion, excitement, depression or stupor. If the toxic action sub¬
sides there may be complete recovery on the part of the tissues, in which
case the mental reactions again become normal. In other cases there
is destruction of many neurons and irreparable injury to many more.
The centres are permanently damaged and the mental reactions there¬
fore remain more or less abnormal. Thus regarded, mental disorders
are abnormal reactions of an associative mechanism that is damaged by
active, or former disease, or by traumatism, or that is defective owing
to some developmental fault. We can now understand the fundamental
difference in the manner in which toxins cause disorder of the intel¬
lectual functions, respectively in acute confusional insanity and in
dementia praecox during its later stages. In the first the toxic storm
still rages, perverting the metabolism of the nervous centres and there¬
fore also their delicate reactive qualities; in the second the toxic storm
has passed over, perhaps many years before, leaving a permanently
damaged nervous mechanism which can react only abnormally. The
brain of an insane person may be likened to a piano, the intricate
mechanism of which is broken, rusted or clogged ; the player represents
the environment to which it can react. Though his skill is perfect, by
fingering the keys he can produce nothing but discord.

If we can regard morbid mental phenomena in this way, we must
recognise the enormous practical importance of the many inimical
forces that are capable of breaking through the first line of defence of
the body and damaging temporarily or permanently the delicate reactive
mechanism of the association centres. My present purpose is to con¬
sider only one group of such inimical forces, namely, pathogenic
bacteria and their toxins. I have already occupied too much of your
time, and I shall give merely a summary of the conclusions that the
evidence now seems to warrant. This evidence is derived from investi¬
gation of the infections in a long series of cases, from the study of focal
reactions, which establish the fact of the pathogenic action of the
bacterium and often reveal much regarding its special toxic properties,
and, lastly, from the observation of the effects of therapeutic immunisation.

As in common maladies the infections are generally complex, though
there is frequently a leading one. The most common seats of infection
are the mucous membranes of the respiratory, alimentary and genito¬
urinary tracts.

I will take first one of the minor forms of mental disorder, namely,
neurasthenia. In this extremely common malady there are always
phobias—pathological exaggerations of protective instincts; there is a
constant sense of fatigue, amounting in some cases to complete prostra¬
tion. The superficial reflexes are exaggerated. Volumes have been
written about it during the past three or four years, and the explanations

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advocated are, apart from the cases in which there has clearly been
physical injury to the brain, almost entirely of a psychological nature.
Shell-shock is really cerebral traumatism and should not be confused
with neurasthenia. The nervous disturbances following terrifying
experiences have also essentially a traumatic pathogenesis, and are
capable of being regarded as purely the effect of psychical traumatism.
True neurasthenia commonly develops without any of these antecedents,
which, however, may precipitate or intensify it. The true cause of
neurasthenia is chronic bacterial infection—exactly the factor that a
hundred authorities ignore. By far the most common infection is an
intestinal one by a neurotoxic micro-organism—an anaerobic diphtheroid
bacillus. I have investigated over ioo cases. Focal reactions and the
effects of therapeutic immunisation have amply established the relation
between this particular infection and the nervous symptoms. A minority
of cases is due to other chronic infections, especially by the bacillus of
influenza, aerobic diphtheroid bacilli and pneumococci.

I have said that there are no pathogenic bacteria that cause insanity
as their characteristic effect. Whilst this is strictly true, the statement
comes very near to being falsified by one sub-group. Much evidence
has now accumulated to show that some species of diphtheroid bacilli
are intensely neurotoxic. They are not nearly so common as the anaerobic
intestinal diphtheroids of which I have spoken. Infection by one of
these intensely neurotoxic diphtheroids is one of the commonest causes
of acute confusional insanity. In some cases of this kind there is what
may be termed diphtheroid saturation. Nearly all the mucous mem¬
branes are infected by the bacilli. These are being passed into the
blood-stream and poured through the kidneys into the urine. Some
cases of this kind of infection have served to demonstrate a fact of great
practical importance, namely, that psychical traumatism may increase
the vulnerability of the nerve-cells and so determine the onset of the
acute phase of the mental disorder. Other bacterial causes of acute
insanity are Streptococcus pyogenes , the bacillus of influenza and the
pneumococcus.

The majority of the cases of insanity that I have had an opportunity
of studying have been such as would be classed among the affective
psychoses. In this group therapeutic immunisation has certainly a
wide and profitable field. I have now investigated many cases and
have in several carried out a course of therapeutic immunisation myself.
It may be said that suppression of existing chronic infections in these
cases is attended, as a rule, by recovery from the mental disorder.
The chronic infections found include those by various species of neuro¬
toxic diphtheroid bacilli, Streptococcus pyogenes , Streptococcus fcecalis
hamolyticus, pneumococcus, Bacillus influenza, bacillus of Friedlander^
.the gonococcus, Bacillus coli communis and a few others.

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Cases of dementia prsecox in the active phase of the disease constantly
suffer from extremely severe bacterial infections of various kinds.
Neurotoxic diphtheroid bacilli are prominent in most ; they are found
especially in the nasal passages and the genito-urinary and intestinal
tracts. Chronic intestinal infections by pneumococci are very common.
In several cases made the subject of a general bacteriological investi¬
gation and immunised with autogenous vaccines, the progress of the
malady appears to have been arrested.

I have no bacteriological data with regard to epilepsy, and I would
merely say that in the present position of knowledge investigations of
the intestinal flora by anaerobic as well as aerobic methods would
probably throw some light on the toxic factor that is undoubtedly
present in this malady.

In cases of senile insanity there are always severe chronic bacterial
infections. The most vulnerable tissues are those of the cerebral
arterial system, and chiefly, though not exclusively, through toxic injury
to this the association centres become involved.

Lastly, in dementia paralytica a spirochaete infection of the brain has
been shown to be an essential factor. According to the orthodox view,
it is the exclusive cause of the disease. Bacterial infections are, however,
always added, and they are, I maintain, of equal importance in the
pathogenesis of the malady. Spirochaete infection alone of the brain
will produce only cerebral syphilis and not dementia paralytica. It is
certainly bacterial infection and not the spirochaetal one that kills the
patient.

( 2 ) Seventeenth International Congress of Medicine, London, 1913. Section XII,
Psychiatry ; Pt. II, p. 128.

The Psycho-pathology of Alcoholism and Some So-called Alcoholic
Psychoses.(}) By C. Stanford Read, M.D., Physician to
Fisherton House, Salisbury.

The social problems connected with alcohol are always before us,
but social reconstruction after the great war has brought them into
greater prominence than ever, while America having gone “ dry ” and
the prohibition campaign starting in this country have brought
the question of alcohol home to even the unthinking section of the
community. In the past we have had the physiological effects of
alcohol put before us almost ad nauseam , and everyone is fully aware of
the disastrous wide-spread results of excessive drinking. Well-meaning
temperance reformers are continually pointing out the intimate relation-

(') Read at the South-Western Branch of the Medico-Psychological Association,
Portsmouth, April 23rd, 1920.

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ship existing between alcoholic excess and illness, crime and pauperism.
Not so very long ago in the press, we had the almost amusing incident
of a manifesto issued by a list of eminent physicians, who decried its use
in medicine, followed not long afterwards by another manifesto signed
by an equally eminent catalogue of medical men, who laid much emphasis
on the beneficial effects of alcohol as a therapeutic agent. The personal
factor is always apt to colour one’s views, and I may be no exception to
the rule. It is a common fallacy to suppose that science is free from
bias and prejudice, but the facts I shall bring before your notice with
regard to the relation of alcohol to mental disease will tend to indicate-
their presence.

Now in order to have an adequate grasp of any problem, it seems
evident that its study should be approached from every point of view,,
yet until recently the psychological aspect of alcohol has been left
mainly untouched. The purport of this paper is to dwell superficially
on the light that modern psychology has thrown upon the relation
existing between alcohol and the psychoses.

It seems feasible at the outset to presume that mankind all over the
globe desires and indulges in fermented liquor for some deep-seated
reason. Yet we must, on analysis, come to the conclusion that man ration¬
alises freely on this point when he gives his so-called reasons for drinking,
and that it is but seldom that the real impulse lies in his consciousness,,
but that unconscious motivation is at work which in the main has as its
object the saving of individual mental pain. Trotter ( 2 ) on this point
says, “ Alcoholism almost universally regarded as either, on the one
hand, a sin or vice, or, on the other hand, as a disease, there can be
little doubt that in fact it is essentially a response to a psychological
necessity. In the tragic conflict between what he has been taught to
desire and what he is allowed to get man has found in alcohol, as he
has found in certain other drugs, a sinister but effective peace maker, a
means of securing, for however short a time, some way out of the prison-
house of reality back to the Golden Age. There can be equally little
doubt that it is but a comparatively small proportion of the victims of
conflict who find a solace in alcohol. The prevalence of alcohol and
the punishments entailed by the use of the remedy cannot fail to impress
upon us how great must be the number of those whose need was just
as great, but who were too ignorant, too cowardly, or perhaps too brave
to find a release there.”

One must lay stress, too, upon the effects alcohol has in promoting the
social instincts and in paralysing the repressing forces of social taboos.
The pleasure that emanates from its imbibition is by no means mainly
physiological in origin. It also is due largely to the narcotic effect
exerted on the higher mental processes, especially social and ethical
inhibitory, whereby those, which normally are controlled by these and

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4920.]

•kept from consciousness through repression, are released. The mere
lessening of inhibition, by which means a man feels a greater freedom of
his ego, brings a sense of elation.

In the face of this view-point, the question of prohibition takes on a
■different aspect. Many of us are inclined to prophecy that total
prohibition would tend to cause an increase in varying types of neuroses
and psychoses, and regret that instead of such a measure some means
were not scientifically advocated to remove where possible the under¬
lying defects that render alcohol a necessity, and an apparent menace to
society generally. Ferenczi ( s ) says, “The one-sided agitation of
temperance reformers tries to veil the fact that in the large majority of
instances alcoholism is not the cause of neuroses, but the result of them,
and a calamitous one. Both individual and social alcoholism can be
■cured only by the help of psycho-analysis, which discloses the causes of
the ‘flight into narcosis’ and neutralises them. The eradication of
alcoholism only signifies an improvement in hygiene. When alcohol is
withdrawn, there remains at the disposal of the psyche numerous other
paths to the ‘ flight into disease.’ And when, then, psycho-neurotics suffer
from anxiety hysteria or dementia prsecox instead of from alcoholism,
•one regrets the enormous expenditure that has been applied against
alcoholism, but in the wrong place.”

Psycho-analytic investigations have shown that the most important
-of the repressed impulses released by alcohol is a homosexual one, as
is illustrated by the fact that excessive drinking usually takes place only
in the presence of the same sex, and by the patent affectionate behaviour
between drunken men not uncommonly observed. The great function
of the social tea in woman’s sphere possibly may indicate to some
■extent feminine homosexuality in a subliminated form, and it has been
suggested that the increased share in the world’s work to which
woman is adapting herself rapidly may tend to lead her to a greater
desire for and indulgence in alcohol. If we accept the Freudian
theory that in the early ontogenetic development of every individual
a homosexual element is normally present which in after years should
and usually becomes sublimated, it is not surprising to see hidden
manifestations of this impulse in later life, especially when some factor
such as alcohol has destroyed that sublimation. Homosexuality is,
however, so abhorrent to the ego-ideal that it can only mainly show
itself in a veiled form, or through mental conflict perhaps produce
symptoms of mental unsoundness which I shall refer to later. It is true
that solitary drinking often exists among dipsomaniacs, in which case
there probably exists a deeper regression to an auto-erotic stage where
the self is all-sufficient for gratification and the external world shut out.

Other factors, though, besides the homosexual one may have intimate
relationship with alcoholism, but study has shown that among the

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unconscious impulses to excessive drinking discrepancies in the
emotional life and sexual desires are mainly concerned. The tendency
to this form of indulgence bears testimony, therefore, to the prevalent
defects in our psycho-sexual life of which we are otherwise unaware.
The moderate drinker may find his mental conflicts soothed and some
components of his desires gratified, but in others where the conflict is
severe and the soil psychopathic, alcohol, by aiding regression and
annulling sublimation, may help to bring about abnormal symptoms
well known to the psychiatrist. Yet, even then we constantly see
evidence of psychological compensation to the self. According to the
amount of alcohol taken, different degrees of regression may occur, and
at the level reached different conflicts may be unearthed.

Pierce Clarke,( 4 ) of New York, whose analytic researches in mental
disease have been so fruitful, points out many other repressed sexual
factors which he traces in the alcoholic’s symptoms and reactions. He
draws attention to the fear and restlessness which introduces so-called
dipsomaniac attacks, which, as in other nervous conditions, are rooted
in conflicts and repressions of the sexual desires, and sees sex symbols
in the certain animals which are always visualised by the alcoholic
deliriant. Most baldly do we find a sexual content in the projection
symptoms of the so-called alcoholic paranoiac, so that to negate this
factor in the {etiology seems an absurdity. Another impulse by no
means uncommonly laid bare through alcohol is the aggressive or
sadistic one. Through the readiness with which some men will quarrel
and fight under its influence, the man in the street has himself been led
to think that a man’s true character comes out when he is drunk, and
has quoted “/« vino veri/as” Clark states that though fortunately all
drinkers do not become criminal, still alcohol permits hidden criminal
desires to work out, and thinks that many crimes seem to be discharges
of the need of a “ howling drunk.” Whether the repeated urgency of
the alcoholic desire is in any way attributable to the desire to stimulate
the erogenous zone of the mouth as some Freudians would think in the
case of sweet-sucking and smoking is, I think, a very doubtful theory.
Clark, too, surmises that the erotic working of the love potion which
plays such a great role in mythology is really alcoholic in its nature,
and thinks that wine, being often a symbol of conception or fruitfulness,
drinking to someone’s health is wishing that the life principle in wine
may do him good.

That alcoholics are the victims of severe mental conflict certainly is
confirmed by their not infrequent attempts at suicide. We know very
little of the deeper motivation which impels an individual to attempt
his life, but it is probable that it signifies a longing for Nirvana, and
involves the furthermost limit of that flight from reality which in some
degree or other tends perhaps to be the most fundamental human trend.

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The drunkard’s humour is well known. He will never be serious and
will turn everything into a joke. This mental attitude is believed to be
largely due to the fact that he must keep away from painful complexes
which would be apt to come into consciousness did he not adopt such
a habit. The affable, joky and hail-fellow-well-met type of patient is
not unfamiliar to us in asylums among this class of patient. This
compensatory reaction results in the individual becoming oblivious to
his degradation, feeling no shame at the loss of the finer feelings he
once had, and having no self-reproach for the ruin he may have brought
upon himself and others.

Though the setiological factors connected with alcoholism are mani¬
fold, enough has been already said to see that, as psychiatrists, we must
no longer be satisfied in future with the banal and superficial explana¬
tions of heredity, degeneration, bad educative influences, etc., but see
that, in each case, we have an individual problem to face with its own
particular life-history, which must be probed and analysed to unearth
the sources of the mental unrest which has necessitated alcohol as a
refuge.

Let us pass on now to the consideration of some of those abnormal
mental states that usually are brought under the grouping of the
alcoholic psychoses. Our psychiatric text-books are apt to be extremely
conservative, so that the budding student of to-day tends to find
therein many superficial and out-of-date conceptions of mental disease
which may warp and handicap his future outlook. I refer here mainly
to what we may aptly term the “functional” or “ biogenetic psychoses.”
At any rate, the question of alcohol in its relation to mental disease
requires much reconsideration when reviewed in the light of modern
knowledge. The President of this Association in his Presidential
Address in 1918 quoted Sir Robert Armstrong-Jones, who is stated to
have said that if only the evils of alcohol and venereal disease were
disposed of, then half the problem of insanity would disappear with
them. Would that I could think this problem could be so dis¬
posed of, even partially. This is precisely the superficial viewpoint I
wish to endeavour to combat, and much that has already been said
points in a very different direction.

There seems no doubt but that our deductions have been often
largely at fault in regarding alcohol as the important causative agent in
the production of insanity, incidence being confused with cause, and
we now see that it is needful to seek further for more remote and
deeper factors. Bevan Lewis, in his studies, showed the relationship
existing between poverty, want, anxiety, and associated moral factors
and mental derangement. He made a claim of dissociation of alcohol
and insanity. He found that the least intemperate communities had
the highest rate of pauperism and insanity, while the most intemperate

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communities had the lowest rate of pauperism and insanity. That is,
when prosperity was greatest and funds for intemperance were available,
poverty and mental stress were least and insanity was less prevalent.
Statistics from the “ wet ” and “ dry ” states in America seem only to
confirm this. Mott comes to the conclusion that insanity does not
keep pace with the incidence of alcohol, and he has pointed out that
hepatic cirrhosis is very rare in asylums, from which fact we may deduce
that most people will tolerate any amount of alcohol, up to extensive
physical disease, without becoming insane, and that this only happens
when there are other important factors present.

Somewhat recent work by Stocker would seem to indicate that
alcohol can only bring about acute insanity, and he has shown that the
cases of so-called chronic alcoholic insanity of all kinds are really cases
of epilepsy, dementia praecox, etc., merely coloured by the added factor
of alcoholism. That some acute mental disorders are often caused by
excessive drinking is patent, but even here a predisposing functioning
must often be present. Such psychoses come little, if at all, into the
province of this paper. Nor do I allude in any way to those chronic
demented states brought on by long-continued excess in alcohol, and in
which the ill-effects are shared by the whole body.

The psychogenic factor is specially prominent in so-called alcoholic
hallucinosis and alcoholic paranoia, and it is in these states that the
pathogenesis is particularly interesting. Though we always find them
grouped under the heading of “ alcoholic psychoses,” we shall see that
there are many factors which should make us doubtful as to the
scientific accuracy of this. Certainly from the symptoms portrayed
the relation between them and alcohol is nothing like as evident as it is
in Korsakow’s psychosis or delirium tremens. We find no toxic
organic signs, such as tremor, neuritis, and speech defects, while the
sensorium is usually unclouded, orientation is undisturbed, memory
unimpaired, all or some of which at any rate we should presume to be
affected if a potent toxin had been the main setiological factor. Not¬
withstanding this, some psychiatrists believe that acute hallucinosis
differs only in form from Korsakow’s psychosis and delirium tremens.
Kraepelin sees no important difference between hallucinosis and delirium
tremens, believing that if the more atypical cases of each are studied
the more symptoms in common will be found. Bonhoffer has much
the same opinion. Bleuler has placed the alcoholic hallucinosis in the
category of dementia praecox, and Kraepelin thinks the combination
possible and that the rapid development of alcoholism points itself to
the disease. We must, however, I think, differentiate these conditions,
though we must be prepared to meet with praecox types who have
acute mental exacerbations through the influence of alcohol. Much
depends on how carefully we study the individual case. Cases have

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been reported which failed to recover, and which, though benign at
first, eventually were transformed into a serious chronic psychosis not
to be differentiated from an ordinary dementia praecox. On the whole,
though, the good recovery with insight, the sudden onset, the age of
the patient, the general make-up, and the short period of illness, all
militate against the so-called alcoholic hallucinosis being classed with
dementia praecox. Other observers regard hallucinosis as allied to
manic-depressive insanity because cases have been met with where
alcohol at one time produced hallucinosis and at others manic attacks,
and also because of the personality, the mental precipitating factor, and
quick recovery with insight. We need not pursue this nosological
discussion further, for it only tends to show the artificiality of our
grouping, and how, on deeper study, more and more the various
functional psychotic disorders are related.

What I have more in view is to show that the toxin of alcohol is not
the main agent in causation but only contributory. We are ever too
apt because of the alcoholic history to regard any other element as
unworthy of notice, though the most superficial analysis will reveal nearly
always an important emotional factor as the real precipitating cause.
The patient may have drunk as heavily many times before with no mental
ill-effects, but on this occasion with the added psychic factor the
hallucinosis is produced, and perhaps after having ceased drinking some
days. It is interesting, too, to note that the patient himself often has
some idea of the right cause of his breakdown, and he is the more led to
do so because the content of his hallucinations has intimate reference
to the emotional situation which acted as the psychic trauma. One
must also lay great stress on the fact that a precisely similar psychotic
picture may be seen where alcohol can be quite excluded as a possible
agent. Many observers have drawn attention to this, and Turner ( 6 )
stated ten years ago in speaking of acute hallucinosis, “ It is probably
within the experience of many who have had a large experience that
such a combination of symptoms often arises without alcohol being a
factor.” Because, then, of the absence of toxi-organic signs, the
definite emotional trauma which is practically discoverable in the
hallucinatory content, the frequent possibility of excluding alcohol in
the history, the onset often occurring some time after alcohol is
withdrawn, and tue fact that alcohol has often been taken in excess
before without mental harm when no mental conflict was present, we
must scientifically look upon this hallucinatory condition as of purely
psychogenic origin, and not in future group it under the heading of toxic
psychoses.( 8 ) This applies as well to the various paranoid states which
are frequently met with and having supposedly an alcoholic origin. In
these states we see the well-known psychological mechanism of “pro¬
jection,” which means that the individual projects his inner repressed

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desires upon the external world so that he attributes these to others in
his environment. Projection is, then, a method of defence, and
represents an effort at repression which is only partially successful.
Not being able to obliterate the disagreeable desires, the repression
does manage more or less completely to prevent the recognition of
ownership. That the mechanism is prevalent in our daily life is
apparent enough on reflection, but it is seen in its extreme degree in
the various paranoid psychoses which often have a distinct relationship
to alcohol, this latter being often superficially taken as the sole cause
thereof. It has already been stated that Freudian investigators have
found that the repressed impulses productive of the paranoiac states are
homosexual in nature, and upon this they base their explanations of the.
various projected delusions or hallucinations which characterise these
conditions. The negation and projection of this impulse may thus
bring about the morbid states of persecution, jealousy, erotomania and
grandeur. Perhaps the most characteristic psycho-pathological result of
alcoholism is the delusions of jealousy, which would be accounted for
mainly by the psycho-analytic school as follows: By reason of the
development of the latent homosexual impulse through probably some
emotional situation, the individual’s capacity to be attracted by the
opposite sex is lessened and he becomes relatively or absolutely
impotent, which may be also perhaps augmented by the toxic effect of
the alcohol. This feeling of impotency is abhorrent, so that to gain
fresh excitation he is tempted to desire, or to actually commit adultery.
Through projection he believes that it is his wife who has had this
desire, or who has committed the act. The homosexual impulse, only
partly repressed, is projected in the same way, and he accuses his
wife of being in love with the very men upon whom he has placed his
desires—a delusion perhaps later generalised to all men. Alcoholism
was not therefore the deeper cause of the paranoiac state, but it was
rather that in the insoluble conflict between the conscious heterosexual
and repressed homosexual unconscious desires he fled to alcohol as a
refuge. This, by sacrificing the sublimations, brought the homosexuality
nearer the surface, but the impulses connected with it being so contrary
to the ego-ideal, consciousness had to at once keep it away from
awareness by means of projection and thus causing delusions of jealousy.

In the late great war I found that paranoid states were particularly
frequent among those who became mentally afflicted, and it is
interesting to reflect upon the various possible aetiological factors. Some
French alienists laid great stress upon alcohol as a causative agent in
the war psychoses. Lepine( 7 ) went so far as to state that it was the
primary and sole cause in one-third of his mental cases, and more
than half—perhaps two-thirds—were influenced by it. He is supported
in his contention by Charon and Hoven.( 8 ) If the observations and

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deductions of these workers are in any way true, and they have not
been led away by a conscious or unconscious prejudice against alcohol,

I can safely say that the cases met with in the British army have been
very different. Reserving under the heading of “ alcoholic psychoses ”
those cases that were purely toxic in nature, my statistics at Netley( 9 }
only showed a percentage of 1 ’6, while Eager at the Lord Derby War
Hospital found only just over 1 per cent., and remarked thereon that
the small percentage of alcoholic cases reflected great credit on the
abstinence of our army in the field. In seeming opposition to this,
Hotchkis( 10 ) of the Dykebar Hospital, found 18 percent, suffering from
alcoholic insanity. He states that this group of his included all the
varieties of mental symptoms found in this form of mental disease—as
though the term “alcoholic insanity ” defined a clear-cut clinical picture.
He speaks of cases of delirium tremens and chronic delusional states,
and between these two classes those who showed various symptoms
such as confusion, depression, subacute excitement, and in practically
all cases hallucinations. However, he qualifies his nosological con¬
ceptions a good deal by remarking that “ though alcoholism was a
prominent feature in predisposing to a mental breakdown, of still
greater importance was the strain and stress of the campaign, and had
it not been for this the breakdown would either never have occurred or
would have been postponed.” In answer to Hotchkis’s findings I can
only state that I saw no evidence of the many cases of delirium tremens
he speaks of. It is true that a certain number of soldiers broke down
very soon after having had leave, some of whom on that occasion had
imbibed too freely and others had not. But I aver that the factors
mainly causative in the breakdown were certain mental conflicts
connected with worry, mainly domestic, brought about while on leave,
and not the alcohol with which some of them endeavoured to drown
the trouble. The discovery that the wife has been unfaithful, the
possible finding of an illegitimate child, the illness of someone near and
dear coupled with the dire fact that swift return to the battlefield was
imperative and imminent—these were the psychogenic factors that lay at
the root of the psychopathic trouble to follow. If instead of using that
almost meaningless phrase “ stress and strain,” which is only useful
as a cloak for ignorance, Hotchkis had substituted “ mental conflict,”
his latter remarks which I have just quoted would mostly agree with
mine, but they hardly warrant him, in my opinion, placing so many
under the heading of “alcoholic insanity,” for he definitely states that
the alcohol was only predisposing.

In my book on Military Psychiatry in Peace and War, I have
quoted from my alcoholic paranoid cases in order to illustrate amply
the subject-matter of this paper. There I refer to a soldier who had
often been crimed for drink while in the army, and who frankly

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admitted that he drank freely when on leave shortly before the
outbreak of his psychosis because he was so worried, having found his
wife unfaithful. It was this psychic factor which tended to render him
psychotic. He had drunk as many times before, but retained his
mental health when no special mental conflict had been present. I
confirm my point of view still more by quoting a case which presented
a very similar syndrome, where the psychosis developed after a leave
fraught with personal worries—the death of his father and the enforced
leaving of an invalid mother—and here no alcoholic history was
traceable. Roughly to include these cases under the term “ alcoholic
psychosis” is clearly hardly defensible. Though I have dwelt upon
active service experience, I have only done so because I had in that
domain special opportunities for study. My remarks, of course, apply
equally to the alcoholic paranoid cases of the civilian.

Dipsomania is an alcoholic disorder that most assuredly has a
psychogenic basis. This recurrent and uncontrollable desire for drink,
according to Kraepelin and Gaupp, is closely allied to epilepsy, while
Ziehen believes, though some dipsomaniacs are of an epileptic nature,
others should be placed in the category of periodic melancholia and
mania. Here again we see the pity of regarding such conditions as
disease entities, and the assumed necessity of fitting them into some
recognised nosological pigeon-hole. Juliusburger,( u ) from the psycho¬
analytic standpoint, looks deeper, and holds that dipsomania is a
peculiar mental state with an underlying psychosexual mechanism and
reports analyses in support of his view. Pearce Bailey,( 1S ) of New York,
sees many similarities to epileptic states, such as similar neuropathic
antecedents, the quick and exaggerated reaction to even small
quantities of spirit, the restlessness and anxiety a short time before the
attack, the morbid reproach for long-forgotten misconduct, the
premonitory depression, and amnesia for parts of the attack itself.
However, he believes that dipsomania can better be explained on some
other hypothesis, and that what at first sight seem to be epileptic
explosions can frequently be reduced to certain phases of mental disease
the clinical characteristics of which soon become blurred by alcohol, or
to the influence of some recurring psychic motive.

The probability is that the psychic factors responsible are various and
must be studied in each individual case. It is certain that there is
always much emotional instability and mental conflict, both of which
provoke periodic alcoholic excess.

In this short paper I have endeavoured to point out that as regards
many of the so-called alcoholic psychoses we have been far too
superficial in our pathological inquiries, and that alcohol largely is only
contributory, and more a result of a mental illness than the cause of it.
Alcohol is taken to promote the social instincts, and alleviate and

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narcotise the many mental conflicts to which we must all to some
extent be victims. It thus constitutes itself a psychological necessity in
modern civilisation. In excess its effect tends to destroy sublimation,
and aid mental regression and in this way may help to precipitate a
psychosis. The regression may be of various degrees, and thus bring
into active conflict with the personality different impulses and desires
previously more or less successfully repressed. Of these the homosexual
impulse is found by analysis to be the most frequent, the resulting
conflict being very liable to result in paranoiac states. A deeper study
of the so-called alcoholic hallucinoses and paranoid psychoses reveals
psychogenic factors which should be looked upon as the real patho¬
logical basis of the abnormalities. It must be noted, too, that by means
of alcohol the psyche defends itself against mental pain, pleasure is
gained by the freedom from inhibitions, and compensations occur, though
so often at the expense of sanity. If such views as I have put forward
are in any way true, many of these psychoses should be differently
classified. Society, too, must bear in mind the psychological aspect of
the drink problem if its solution of it is to be a happy and successful
one. Those of us who are academically interested in such a vital
subject will watch the results of prohibition in America with intense
interest. Karpas, of New York, in speaking of the complexity of mental
life and its direct relationship to our longings and cravings, which are
determined by conscious and unconscious forces, expressed my views
when he summed up the essence of these questions in the following
words : “ Some of our cravings are gratified ; others find realisation in our
dreams ; still others are repressed and compensated. In fact, our mental
life is nothing but a readjustment of complex reactions. The poet finds
recourse to his phantasies, the philosopher to his theoretical speculation ;
the scientist resorts to his inventions and hypothetical theories ; the well-
balanced normal individual seeks adjustment in healthy activities—art,
literature, science, occupations, sports, etc.; but the individual with a
poorly endowed constitution finds refuge in neurosis, psychosis, alco¬
holism, drugs and other vicious habits. We must recognise that the
alcoholism is nothing but a compensation for a complex, the fulfilment
of which was denied by reality.”

Our mental health depends so largely upon our capacity to face the
stern realities of life, but how many of us for however short a space of
time do not find gratification by dwelling in the land of make-believe?
It is by means of alcohol that the stern realities of life can seem for the
time less harassing—that our burdens seem lighter. Let us not forget
that the underlying motive in all voluntary conduct is the pursuit of a
conscious happiness. To so many, and especially those whose
emotional life is in conflict, alcohol materially helps towards that goal.

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( 5 ) W. Trotter, Instincts of the Herd in Peace and War, Fisher Unwin, 1916.
—(’) S. Ferenczi, Contributions to Psycho-analysis, English translation by Ernest
Jones, Richard Badger, 1916 .—(*) Pierce Clark, " A Psychological Study of
Alcoholics,” Psycho-analytic Review, vol. vi, No. 3.—(‘) John Turner, “Alcoholic
Insanity," Journ. Ment. Sci., 1910.—( 6 ) For excellent discussions on the alcoholic
hallucinoses refer to articles by Carl von A. Schneider, Psychiatric Bulletin, vol. ix,
No. x, and by G. H. Kirby, Psychiatric Bulletin, vol. ix, No. 3.—( 7 ) Jean Lepine,
Troubles mentaux de la guerre. Paris: Masson, 1917.—( 8 ) Ren£ Charon,
“ Psychopathologie de guerre,” Progres medicale, June, 1915; Hoven, “Mental
Diseases and the War,” Archiv med. Beiges, Paris, May, 1917.—(•) C. Stanford
Read, Military Psychiatry in Peace and War, H. K. Lewis & Co., 1920.—( 10 )
R. D. Hotchkis, " An Analysis of Cases admitted during the First Year to Dykebar
War Hospital,” Journ. Ment. Sci., July, 1918.—( n ) Otto Juliusburger, “ Contri¬
butions to the Psychology of the so-called Dipsomania,” Zentralblatt fur
Psychoanalyse, July-August, 1912. —( IJ ) Pearce Bailey, Clinical Varieties of
Periodic Drinking, Nervous and Mental Disease Monograph Series, New York,
No. 9.

The Significance of Acidosis in Certain Nervous Disorders .(*)
By B. H. Shaw, M.D., Medical Superintendent, County Mental
Hospital, Stafford.

The clinical evidence of acidosis is the detection of acetone bodies
in the urine. Acetone is formed from diacetic acid by the splitting off
of carbonic acid, the origin of diacetic acid being in part from fats
and in part from proteins. Oxybutyric acid is also formed from
diacetic acid by reduction, consequently the presence of acetone
bodies in the urine always means that acidosis is taking place. A
delicate test is that known as Rothera’s, which is quite simple, and will
detect acetone in minute dilution :

To about a gramme of ammonium sulphate in a test-tube add a few cubic centi¬
metres of urine, a couple of drops of a freshly prepared solution of sodium nitro-
prusside, and a cubic centimetre of strong ammonia. A purple colour develops.
Nitro-prusside can also be used to detect diacetic acid.

Synchronously with the production of acidosis there is a retarded
oxidation as the sodium carbonate of the plasma, which normally
carries off the C 0 2 , tends to be neutralised, and as a result tissue-cells,
for their own protection, set free autolytic enzymes of various kinds,
which attack the proteins and lipins of the cell itself in order to
liberate ammonia, with the object of neutralising the cellular acidity;
imbibition of water by the cell-wall now occurs, and the slowing down
of all cellular activities ; fatigue consequently comes on much sooner
with reduced alkalinity.

Acidosis is by no means infrequently met with. The already
published literature on the subject gives the following states in which
it occurs:

(*) Read at the Staffordshire Branch meeting of the British Medical Association,
February 26th, 1920.

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Diabetes mellitus, fevers, nephritis, phosphorus poisoning, fasting, grave
anaemias, deranged digestion, auto-intoxication, chloroform and ether anaesthesia,
and what is known as biliousness.

I frequently meet it in my practice and many fresh admissions are
found to suffer from it. It is especially frequent in acute delirium,
melancholia, confusional and stuporose states, and epilepsy. It may
indeed very possibly be an important aetiological factor in the produc¬
tion of epileptic states, for reasons to be referred to later. The
following notes are taken from two recent deaths, resulting from extreme
acidosis:

(1) E. J—, a mischievous, weak-minded boy of impulsive tendencies, act. 15,
admitted in September, 1917. He was well nourished and took his food very well
indeed. He had had no fits previously. During the night of December 30th,
1919, he had a severe typical epileptic fit, and lapsed into a condition of cerebral
irritation with paresis of his legs and conjunctival injection. Specific gravity of
urine 1024; no albumen or sugar, but strongly positive to acetone. He was put on
alkaline treatment and improved, the acetonuria disappearing, and he continued to
take his food well. On January 10th he again developed strong acetonuria, which
did not yield to alkaline treatment, and he died at 9.40 a.m. on the 16th.
Post-mortem : Intense minute injection of the pia arachnoid in a patchy fashion,
especially marked over sulci and along veins, one large patch extending over the
vertex of the left hemisphere; numerous punctae cruentes on section of the
cerebral tissue; strong acetone reaction in cerebro-spinal fluid and blood. Micro¬
scopical examination showed minute vascular engorgement, diffuse and central
chromatolysis of the neurone body and degenerative changes in nuclei—in other
words, primary degeneration of the nerve-cell. The suprarenal glands showed
some congestion and fat deficiency; other organs apparently normal.

(2) J. H—, a well-developed man, xt. 49, admitted on February 4th in a state
of acute confusion, had been ill for six weeks prior to admission. He was, on
admission, in a state of restless, noisy excitement, continually wet and dirty,
rendering it impossible to collect his urine for examination. He was put on milk
and other extra diet, which he took satisfactorily. He was extremely feeble when
admitted, became gradually weaker, and died at 2.30 a.m. on the 10th. Post¬
mortem : Cadaver in good condition, marked opacity and thickening of the
pia arachnoid with much recent minute injection and patchy ecchymotic areas.
Brain tissue showed numerous punctae cruentes on section. Acetone reaction
strongly marked in cerebro-spinal fluid, which was in excess, in pericardial fluid
and in the blood. Microscopical examination showed engorgement of vessels with
some minute extravasations, diffuse and central chromatolysis of cells, nuclear
changes and absence of pigment. Suprarenal glands softened, scanty fat; liver
somewhat fatty; other organs normal.

A certain amount of acetone and diacetic acid will be found in
ordinary post-mortem decomposition, but nothing like the quantity
present in the body-fluids in cases of death from acetonaemia. The
examination, of course, must be done as soon after death as possible.

In the case of the boy J —, his first fit occurred at a very usual age
for the onset of so-called idiopathic epilepsy, also there was in this case
no question whatever that inanition had anything to do with the
causation; the boy looked after himself very well indeed in that
direction.

Dealing with the post-mortem appearances in both these cases, I may
state that in post-mortem examinations on mental cases it is the
exception to find a normal transparent pia arachnoid. Secondly,

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in long-standing cases of epilepsy almost the only change met
with may be a thickening and opacity or milkiness of the
pia arachnoid ; this thickening and opacity I regard now as most
probably due to congestive attacks resulting from acid intoxication.
These congested areas are most pronounced over the vertex,
where the membrane is thickest and the underlying neurones mainly
motor. Thirdly, after death in status epilepticus there is intense con¬
gestion of the membranes, and the cells show the profound structural
changes of primary degeneration—structural changes which I have
shown to be also present in the cases mentioned. It is of interest
to note here that the meningeal appearances in these cases are very
similar to many I have seen in the Balkans as a result of malignant
malaria, and in which the symptoms indicated intense toxaemia, no
doubt due to deficient oxidation as a result of the destruction of vast
numbers of erythrocytes, and also to the haemoglobin and oxyhaemo-
globin set free in the plasma behaving as weak acids. Addison, Lusk,
and Graham consider that the rise in heat-production in severe
anaemias is due to the pathological production of lactic acid from
carbohydrates in consequence of an inadequate supply of oxygen to the
cells. Recently I have had two cases of confusion following malignant
malaria contracted at Salonica, one of whom had definite acidosis
periodically while here.

I will now mention briefly some cases which came recently under my
notice:

(1) J. P —, a young woman, act. 22, single; case of acute delirium of three days’
duration prior to admission ; cause, mental shock; no insanity in family. Aceto-
nuria on admission, sp. gr. 1030, no albumen or sugar present; under treatment
practically recovered in three weeks.

(2) D. P—, woman, aet. 47 ; four previous attacks, first at age of twenty-three,
simple melancholia with acute confusional periods, which synchronise with aceto-
nuria; takes her food well, and in good condition. I may say that with her last
acetonuric attack tubercle bacilli and slight albumen appeared also in the urine,
neither of which can be found now. She responds very well to alkaline treatment.

(3) N. W—, woman, aet. 42; married ; acute confusion, acetonuria on admission ;
cause, over-work and worry; history in this case of not taking her food prior to
admission. Under treatment.

(4) V. H—, woman, aet. 36, married; melancholia with acute confusional
attacks synchronising with acetonuria and responding well to alkaline treatment;
always takes her food well; cause, worry and mental shock.

(5) E. S—, woman, aet. 48, single, no history; melancholia, acetonuria on
admission ; takes her food but otherwise very resistive.

(6) E. L. S—, man, aet. 29; stupor; admitted with acetonuria, very intense
reaction ; on alkaline treatment acidosis cleared up ; mental condition not appre¬
ciably improved as yet. Possibly the injury to the neurone in this case precludes
recovery.

(7) 'G. H—, aet. 30, military case; confusional mental condition associated with
acetonuria, pulmonary tuberculosis also present; cause given as stress of campaign.

(8) W. R—, man, aet. 33; violent epileptic ; acetonuria present with outbreaks
of excitement; slight trace of sugar on one occasion ; said to be a heavy drinker.

(9) S. K—, man, aet. 56; simple melancholia; a little while ago got a sudden
attack of acute confusion and violence synchronising with strong acetonuria;

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much improved under treatment; cause given as over-work; always takes his food
satisfactorily.

(10) H. P —, boy, set. 17; strong family history of insanity; father, two
brothers and sister have been insane; on admission much acetone present in urine;
in a state of acute excitement and quite incoherent; rapidly recovering under
alkaline treatment.

(11) F. D—, male, set. 20; case of masked epilepsy; acetonuria present
during attacks.

(12) S. G—, set. 28; epileptic, very violent, and impulsive; acetonuria during
attacks.

In cases which recover it is noteworthy that the improvement
synchronises with diminishing acidosis. These are only a few of many
cases: For example, acetonuria has been present in ten out of the past
• twenty-five admissions here and the mental disorder in all ten was of
the confusional type. With the exception of four of the above-
mentioned cases who were recent admissions, fasting could be excluded
as an aetiological factor.

I must now refer to the direct effect of acetone bodies and bile acids
in “vitro on red blood-corpuscles. If red corpuscles are washed and
incubated at blood temperature with small dilutions of these substances
they are soon hsemolysed; this simply means disintegration of the
cells. Taking into account the other still more destructive ferments
present in acidosis, it is obvious that these substances in the blood and
body-fluids must have a most irritative and disastrous effect on tissue-
cells. This is already evidenced by the degenerative cell changes
noted in the post-mortems alluded to. If the acidosis is intense or
continued for a length of time, or if the patient gets frequent recurrences,
permanent damage to the neurones must ensue.

Now, as regards the varying nervous symptoms met with at different
ages in acidosis, we have to consider the action of cholesterol, which is
very soluble in acetone. The adult human brain contains an extra¬
ordinarily large amount of this substance—practically 2 per cent, of wet
tissue—but in children there is relatively much less ; thus, in a child of
three months old there is only ‘69 per cent. It can be shown in vitro
that this substance has a protective function on erythrocytes with
regard to the action of haemolytic agents such as autolytic ferments and
acids. It may therefore be assumed that its presence in the brain in
such large amount indicates a similar protective action as regards the
delicate neurone; any excess, therefore, of acids or autolytic enzymes
in the blood of young persons might readily lead to different nervous
symptoms and more serious neuronic irritation than would occur in
later years, when more protection would be available for the neurone by
the increased amount of cholesterol present. It must be added that
the serum of infants is slightly less alkaline than that of adults, and
that the carbon dioxide tension in the alveolar air of infants is lower,
probably due to more active metabolism.

LXVI. 1 7

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Referring to ferment action I have found that the diastatic content
of urine is increased in acetonuria. Reducing the specific gravity in
all cases to 1003, normal urine shows a diastatic reaction of 5 to 10

-—, that is, when incubated at 38° for 30 minutes 1 c.c. of urine will
3 °

convert 5 to 10 c.c. of 1 per mille starch solution into sugar. In
acetonuria the diastatic content is somewhat higher, reaching at times as

much as 25 or even 100 — . Again, it has been shown that pancreatic

3 ^

lipase, which is normally present in the blood, becomes haemolytic if
activated by fat; consequently the more fat there is in serum under
certain conditions the greater would be the tendency towards cell
irritation, such conditions being possibly cholesterol deficiency in the
neurones or plasma or excess of circulating ferments. Here I would
like to mention that the brain is the only organ in the body which
contains no fat.

In reference to this I investigated sera from patients of different
types of mental disorder as regards the effects on them of tryptic
digestion. The sera were drawn at the same time of day in every case
and primarily for syphilitic sera-diagnosis. The method I adopted was
digestion of a definite amount of serum with extract of hog pancreas
and bile for twenty-four hours at 37 0 C. and then neutralising with
N/50 soda, using phenolphthalein as indicator. My results indicated
that the serum in cases of chronic alcoholism, chronic melancholia and
epilepsy showed a higher acid content as compared with others. I
admit the difficulty of determining end-points accurately in such an
investigation, but I took all possible care in the matter and only dealt
with the sera by numbers. It is noteworthy that fits will occur in
chronic alcoholism in a considerable number of cases. As further
evidence of acidosis it may be mentioned that Haig and Krainsky
independently determined that there was a marked fall in uric acid
excretion prior to a fit, and Charon and Briche showed in 1897 that
fits are most frequent during the night time, when the reaction of the
blood tends towards acidity.

Reference to the time-incidence graph of fits occurring in this
hospital during the past week will illustrate this. Again, it is well
known that strongly nitrogenous diet increases the number of fits in
epileptics; here again we have evidence of acidosis, for excessive
proteid disintegration results in excessive acid production, the sulphur
and phosphorus of the broken-down tissues being oxidised to form
sulphuric and phosphoric acids, and these together with diacetic and
oxybutyric acids neutralise much of the alkali of the blood, with result¬
ing acidosis. This is equivalent to carbonic acid poisoning, and the
sodium carbonate of the plasma which normally takes away the CO a

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249

from the tissues tends to be neutralised. It has been shown that
carbon dioxide causes imbibition of water by the red corpuscles and an
increase in their size, hence greater viscosity of the blood and a
tendency to stasis in minute capillaries; it has also been shown that
carbon dioxide protects these corpuscles and possibly therefore other
tissue cells from the action of hsemolysins ; it would thus seem possible
that the presence of excess of carbon dioxide in the blood naturally
resulting from the muscular spasm initiating an epileptic fit may have a
certain protective action on the neurone—this is, however, by the way.
Having in view the case of the boy E. J—, in which acidosis was

during the late evening, and continues so through the night and early hours of
the morning.

undoubtedly responsible for the fit, I have been for a little while back
giving alkalies to a number of cases of epilepsy, and already I notice a
decided reduction in the number of fits in certain cases. I also
interdict salt. It must be remembered that the epileptics I am dealing
with are very chronic cases in whom the neurones are educated up to
the habit of taking fits on the smallest provocation. The best results
are likely to be met with in early cases. It seems to me quite likely
that a fit may be caused in early years by a serious attack of acidosis,
which may soon pass away, but leave the cells in a certain state of
irritation and liable to similar seizures with a succeeding lesser degree
of acidosis; very slight stimuli may eventually bring a fit on, especially
when a hereditary tendency exists. If this should be so it is of the

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utmost importance to recognise the acidosis at once and deal with it
before the habit is acquired.

Some six years ago I pointed out that in mental hospitals a high
epileptic ratio is constantly associated with a high tuberculosis incidence
and vice versa; also that associated with a high ratio of epileptics in
urban relatively to rural districts is a similarly high infantile and early
childhood mortality from tuberculosis, convulsions and atrophy debility
and marasmus, and in addition a correspondingly high proportion of
occupied married women. In this connection I have to point out that
acidosis favours microbic infection as one would expect: thus a large
proportion of diabetics die of tuberculosis.

In 1889, von Mering and Minkowsky found that if the pancreas
be completely extirpated, hyperglycaemia, glycosuria and acetonuria
occurred, and a very interesting and significant fact was that in the
animals experimented on vital resistance to infection was enormously
reduced, so that it was extremely difficult to avoid infection in tht
operation or afterwards, and wounds healed slowly.

We may, therefore, take it for granted that acidosis predisposes to
tuberculosis. A point worth noting in this connection is that excess of
lecithin is present in the serum of tuberculous patients and also in
those suffering from chronic insanity. Again, patients in asylums are
very prone to microbic infection—witness what is known as asylum
dysentery.

In 1898, Biedl showed that by throwing the thoracic duct out of
circulation glycosuria resulted. Schaefer suggested that this was owing
to the absence of a glycolytic ferment derived from the islets of the
pancreas. I suggest, on the basis of amboceptor formation, that the
ferment lacking would probably be derived from lymphocytes. Experi¬
mentally, Bullock determined that the amount of haemolytic ambo¬
ceptor varied directly as the number of mononuclear leucocytes. Now
lymphocytosis is a feature of certain diseases, e.g., tuberculosis, typhoid
fever and malaria. It has also been shown by several observers to be
present in epilepsy. In twenty-one cases of epilepsy—so far as I could
judge uncomplicated by tuberculosis—I found a relative lymphocytosis
present. This lymphocytosis I consider an evidence of increased
ferment action. On this interpretation Biedl’s diabetes would result
from deficient ferment action owing to absence of lymphocytes; con¬
sequently hyperglycaemia will of necessity give rise to increased ferment
action associated with reactive lymphocytosis.

In a leader in the British Medical Journal of February 14th last,
reference is made to an article by Prof. Carmalt Jones, which appeared
in Brain in 1917, in which he states that in considering a man’s nervous
system in neurasthenia the only physiological fact which struck him was
the presence in the blood of an animal under the influence of fear of an

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■excess of sugar destined to supply the muscles with energy, and ascribed
to increased secretion of adrenalin under the stimulation of the sym¬
pathetic ; that the adrenals exercise some protective influence over cells
so far as autolysis is concerned is shown by the fact that cobra toxin—
which is a nervous toxin and haemolytic to washed human erythrocytes,
after being mixed with emulsion of adrenal cortex is rendered inert. It
would appear, therefore, that the adrenals, as well as being concerned
with sugar elaboration, have antidotal properties as regards autolytic
agents ; in sympathetic disturbances we may readily get this function
in abeyance, and as a result serious interference with cell metabolism
and consequent acidosis.

Blum observed in 1901, that subcutaneous or intravenous injections
of adrenal extract in animals caused glycosuria. Herter and Wakeman
also determined that quite small amounts of adrenalin applied to the
pancreas provoked marked glycosuria. Carbohydrate metabolism is
therefore apparently under the control of the sympathetic nervous
system, as is also the protection of the cell from autolytic ferments. It
may therefore be readily understood that disturbance of the sympathetic
system may directly bring about a condition of acid intoxication. This
may occur as follows :

Fright or anxiety produces hyperglycaemia; this is probably due to stimuli
■emanating from the brain, passing over the splanchnic nerves in part to the liver,
inducing acetone formation and the splitting up of glycogen, and also to the
suprarenals, causing a discharge of adrenalin. Constant action of this nature may
lead to exhaustion of the adrenal tissue with resulting loss to the organism of the
protection normally afforded against agents producing cell-autolysis. Further,
adrenalin is in vitro readily precipitated by acetone, consequently the presence of
acetone in the body-fluids directly inhibits the action of adrenalin.

Degenerative suprarenal changes are very constantly met with in
post-mortems on the insane. In epilepsy Prior states that out of twenty
suprarenal glands examined by him degenerative changes were present
in fifteen; also, in addition to adrenalin being readily precipitated by
acetone in solution, its normal destruction in the blood is inhibited by
any tendency towards acidosis. •

As regards a further possible source of acid production, I have been
much struck by the frequent occurrence of pyorrhoea alveolaris in
certain cases of mental depression and confusion, and have examined
as regards sugar fermentation large numbers of streptococci from the
roots of extracted teeth in such cases. All these organisms are strongly
acid on litmus glucose, while negative on salicin, mannite, and lactose.
This is certainly suggestive, and I am at present investigating the results
of proper dental and vaccine treatment on such cases.

I wish now to refer briefly to some further experimental work.

Donath, Hahn, Massen, Pablow and Krainsky have found that a
small quantity of blood taken from an epileptic who is suffering from
a fit produced convulsions immediately when injected into a guinea-pig

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252 ACIDOSIS IN NERVOUS DISORDERS,

or rabbit, but when drawn in the interval between the fits no effect
resulted.

Hewlett states that the injection of epileptics’ blood into animals is
sometimes followed by severe haemolysis.

Krainsky found carbamic acid present in the blood of epileptics in
considerable amount.

As regards the toxic effects of human urine on animals different
authorities arrive at various results, as is to be expected, taking into
account the amount injected and its varying composition as regards
time of excretion, etc. In large quantities normal human urine is toxic
to animals. Bouchard demonstrated that the toxic dose corresponded
to about 45 c.c. per kilogramme of the animal injected. I have found
that urine from a case of acetonuria is strongly toxic when injected into
rabbits. The following experiments will illustrate this and also throw
light on the treatment.

I took two rabbits—both bucks from the same litter, and each weighing 3 lb. I
injected intravenously into No. 1 2 c.c. of urine from a patient suffering from
marked acetonuria, with the following result:

In a few minutes he became drowsy and lethargic, taking no notice of food,
though previously feeding with avidity. Inco-ordination of hind legs set in and
paresis ; breathing, at first rapid, became appreciably slower. In half an hour he
looked very ill, hunched up, fur ruffled, movement of nostrils spasmodic and slow;
remained in one place, resistive to stimuli, shut eyes occasionally. Half an hour
later hind-leg paresis had passed off, although still lethargic and disinclined to
move.

Into No. 2 rabbit I injected intravenously the same amount of the same urine,
but one-third saturated with anhydrous sodium carbonate. This injection had no
apparent effect on the animal.

I had previously ascertained that 2 c.c. of normal urine had no effect on a
rabbit when injected intravenously.

As regards treatment, in mild cases the indications are rest, warm
clothing—in view of the fact that acidosis is nearly always associated
with low blood-pressure; sleep, nutritious diet—avoiding fat, and in¬
cluding plenty of carbohydrates, Bynogen, Allenburys’ diet, and such
artificial foods ; free purgation and alkaline medication. Potassium
♦ citrate is very useful, as, in addition to the fact that it changes into
carbonate in the blood, it provides citric acid, which has the effect of
restoring fat metabolism to normal, thereby reducing directly the
acetonaemia. This, combined with the carbonates of calcium and
lithium and the bicarbonate of soda, makes a very useful prescription.
The more bases given the better. Free ventilation is necessary to
secure an adequate supply of oxygen.

In a case showing more serious symptoms, complete rest in bed, and
in addition to the above, enemata of 20 per cent, glucose solutions ;
while in a severe attack it may be necessary to give glucose or bi¬
carbonate of soda intravenously. It might, indeed, be advantageous to
consider gum-saline intravenously, as Bayliss suggested in wound-shock.

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Glucose, it must be recollected, may behave as a weak acid in the
blood.

Unless absolutely necessary for the provision of sleep, as little
drugging as possible and as little disturbance in the way of chatter
and interference—the exhausted and damaged neurone has quite
enough to put up with. Be firm, and make the patient realise that
his is a serious bodily disorder. In all but the mildest cases send
the patient to hospital as soon as possible. The acetonuria having
disappeared, continue a full dose of the alkali towards evening, and
give a mixture of iron and arsenic. The experiments of Crile show
that in these conditions strychnine is contra-indicated, as it caused cell
changes precisely similar to those resulting from the emotions, toxins
and foreign bodies, viz., hyperchromatism succeeded by chromatolysis.
With regard to means of control of the kinetic drive, Crile also states :

“ Whatever the activation, whether infection, emotion, injury, or Graves’s disease,
morphine measurably controls the outward phenomena such as pulse-rate, respiratory
exchange, sweating, thirst, restlessness, acid excretion, fever, muscular action and
pain. . .

And it is interesting to note that so far back as 1822 De Quincy, in
his Confessions , states opium to be—

“. . . under an argument undeniably plausible alleged by myself, the sole

known agent—not for curing when formed but for intercepting whilst likely to be
formed—the great English scourge of pulmonary consumption . . .”

He considers that he himself was cured of phthisis between the ages
of twenty-two and twenty-four by the regular and continued use of opium.
There is at present here a patient, at one time a confirmed epileptic, who
was given, many years ago, continuous and gradually increasing doses of
opium for a number of years. During this period the fits disappeared,
nor have they ever returned, though for a good many years now the
opium habit has been broken off.

In conclusion, I wish to draw your attention to—

(1) The profound structural alteration in the neurone caused by acidosis and
the extreme danger of permanent injury to it by continuance of the condition or by
frequent attacks.

(2) The urgent need of early diagnosis, and the recognition that such cases are
very ill indeed and need complete rest and proper treatment or they may become
invalids for life and a burden on the community.

(3) The simplicity of the diagnosis.

(4) The fact that, as a rule, acidosis can be readily counteracted by efficient
treatment.

(5) The need—in view of acidosis being a probable aetiological factor in
epileptic states—for careful investigation, and the probability that, if such is the
case, efficient alkaline treatment may cure the condition if recognised at the onset
of the fits. The giving of bromides would seem to be dangerous in such a state,
as it only tends to dull cellular activities. Later on it may be of use in treating
nerve-cells which have acquired vicious habits.

(6) The danger to the patient in not adopting a firm attitude. If such cases are
at once sent to hospital before serious mental symptoms come on there would
soon be marked diminution in the admission-rate at asylums.

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(7) The predisposition to microbic diseases afforded by acidosis, above all to
tuberculosis. As regards children, there are questions which can best be answered
perhaps by the general practitioner: for instance—What is the relationship
between “ biliousness " in children and subsequent tuberculosis ? Are the sexes
equally subject to acidosis ? Does it throw any light on the greater mortality of
male children? With regard to tuberculosis: Is it a question of the optimum
reaction of the medium necessary for the growth of the tubercle bacillus? In
other words, do certain individuals, as a result of errors of nutrition or faulty cell-
metabolism, offer a more favourable pulmonary or lymphatic culture medium for
the growth of the tubercle bacillus than do others ?

Finally, is this whole question of acidosis, within limits, at the
bottom of what we understand by heredity in respect to disease pro¬
cesses ? Is it an effort on the part of the organism in some cases to
autolyse itself? All these questions are of extraordinary interest, and
the whole subject may bring us vastly nearer a proper comprehension of
certain processes which up to the present have been shrouded in
mystery.

References.

Addison, Lusk and Graham.— Journ. of Biol. Chem., 1919.

Bayliss.— Intravenous Injection in Wound Shock , 1918.

Beatty, J.— The Method of Enzyme Action.

Bouchard.— Auto-intoxication , 1894.

Charon and Briche.— Arch, de Neurolog ., 1897.

Citron.— Immunity.

Crile.— The Kinetic Drive , 1916.

Crile and Lower.— Anoci-association , 1914.

Haig.— Uric Acid, 1892.

Hammarsten.— Physiological Chemistry.

Hewlett.— Pathology.

Krainsky.— Neurol. Centralb ., 1897.

Idem.—Mlmoires Couronnes , 1901.

Prior.— Journ. Ment. Sci ., 1920.

Shaw.— Ibid., 1914.

Starr.— Nervous Diseases.

Vincent.— Internal Secretion and the Ductless Glands.

An Analysis of 200 Cases of Mental Defect .0 By J. E. Middle-
miss, M.R.C.S.Eng., L.R.C.P.Lond., Medical Officer to the Leeds
Committee for the Care of Mental Defectives; Late Assistant
• Medical Officer, Gartloch Mental Hospital, N.B.

The cases dealt with in the present paper came under review during
the course of my duties as Medical Officer to the Leeds Committee
uncTer the Mental Deficiency Act. They comprise examples of the four
varieties of mental defectives defined by that Act, viz., idiots, imbeciles,
feeble-minded, and moral imbeciles, and include most of the clinical
types described by writers on the subject. The commonly accepted
(') A paper read at the Annual General Meeting, July 23rd, 1919.

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division into primary and secondary groups has been adopted; a third
group, containing cases which appear to combine the characteristics of
both types, and a fourth group containing “ doubtful ” cases, in which
the data are insufficient to allocate them definitely, being also added.
It has seemed useful, too, to give columns showing the number of cases
corresponding to the accepted clinical types, those complicated by
epilepsy, those exhibiting pronounced stigmata of degeneration, as well
as those showing a definite family history of neuropathic affections,
tubercle, or alcohol respectively. It is obvious that many of these
cases will figure under the several heads. The following analysis then
shows the proportion of cases under each of these heads of the total
number of cases examined, viz., 200 :

Classifications.

Primary

amentia.

Secondary

amentia.

Combined
primary and
secondary.

Doubtful.

Cases asso¬
ciated with
epilepsy.

Cases

showing

stigmata.

Cases

showing

neuropathic

history.

Cases

showing

alcoholic

history.

Cases

showing

tuberculous

history.

146

73 t*r
cent.

I3‘5

cent.

5 P^
cent.

»7

8 5 Per
cent.

29 Per
cent.

126

63 per
cent.

48 s Per
cent .

13 5 Per
cent.

27 per
cent.

Feeble¬

minded.

Moral

imbeciles.

Imbeciles.

Idiots.

Hydro¬

cephalic.

Cretins.

Mongolians.

Micro-

cephalic.

Sclerotic

amentia.

37 5 per
cent.

2'5 per
cent.

103

5 J '5 per
cent.

2 per
cent.

1 per
cent.

4 Per
cent.

1*5 Per
cent.

*■5 Per

cent.

Although the accepted division of cases into primary and secondary
amentia is adopted, some reservations have to be made which will, at
the same time, explain the inclusion of a third, the “ combined ” group.
It may be said that the classification into two broad divisions was
originally adopted in obedience to current procedure. But as the
analysis progressed a conviction gradually grew in the writer’s mind
that such a classification was arbitrary and unsatisfactory, for the
following reasons.

The criteria of primary amentia are the following :

(1) That the mental defect should have dated from birth, in other words, that
there should be no period, however short, in which the mentality was normal.(*)

(2) The frequent association of physical stigmata referred to the various
systems, but which may be broadly described as developmental anomalies.

(3) Evidence of a neuropathic tendency as shown in the family history.

(4) The absence of history of trauma, including in this term not only accidents
(pre-natal, post-natal, and at birth), but such bodily disorders, e.g., meningitis,
hemiplegia, epilepsy, etc., as are usually associated with mental defect as a cause.

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Cases of secondary amentia, on the other hand, frequently show a
period of normal mental development, with the history of a fall, febrile
or other illness, from which the symptoms of mental defect date; or, if
dating from birth, disclose a history of accident or injury at birth, or
of the existence of disease or debilitating influences acting on the child
through the mother before birth. In either case the physical anomalies
frequently associated with primary defect are wanting; but, on the other
hand, there is usually evidence of gross brain-lesion, as exmplified in loss
or impairment of function of one or more limbs, associated with altera¬
tions in the reflexes or sensory disturbance in the affected parts,
tremors, tics, or choreiform movements.

So much for the broad definition of the two types. When one comes
to an actual analysis of cases, however, the distinction between the two
groups is found to be not nearly so precise and well defined as the
above description would suggest. Cases occur, for example, with a
definite history of meningitis or encephalitis subsequent to birth, but
which are associated with stigmata, such as narrow palate, irregular
dentition, malformed ears or cranium, suggesting a primary defect.
When, in addition, there is a neuropathic family history and delayed
development before the onset of the “illness,” the primary factor
becomes relatively more prominent. Such cases would accurately be
described as combined primary and secondary amentia, and they are
by no means uncommon. One is struck, too, by the frequency with
which a history of meningitis or convulsive affection occurs (and no
doubt plays a causative part in the mental defect) as a complication in
cases where there is undoubtedly primary defect. Such cases are
generally described as cases of primary amentia complicated by menin¬
gitis, epilepsy, hemiplegia, etc. Even in those cases where develop¬
ment appears to have proceeded on normal lines, up to the period of
the “ illness ” the alleged cause of the defect, and where there are few
or no stigmata indicating primary deficiency, not infrequently a history is
elicited showing undoubted neuronic defect affecting several members
of the family and rendering the classification, to say the least of it,
doubtful.

Case i. —The case of H. H— is one in point. Walking and talking developed
at usual age. There was a definite history of some cerebral affection, “inflamma¬
tion of the brain,” at 6 years of age, lasting some weeks, during which he
lost his sight and speech. Mental defect noticed subsequently. Ears are large,
forehead small and narrow, the cranium generally small in relation to face.

Family history. —(1) Father, said to be mentally slow. (2) One brother, a
mental defective in an institution. (3) A second brother, aet. 22, low in intelli¬
gence, cannot read or write, poor at figures; vagrant habits. (4) Two other
brothers died of infantile convulsions, aged, respectively, 16 and 8 months. (5) A
fifth brother, aet. 7, has epileptic fits of major type, infrequent but severe. (6) A
paternal uncle died of pulmonary tuberculosis. (7) A maternal uncle (died circa 14),
a mental defective. Such a case as this is a good example of the difficulty I refer
to. The primary neuronic defect as evidenced by the occurrence of amentia and

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257

epilepsy in other members of the family does not need emphasising, and yet super¬
ficially it would be described as secondary amentia.

Case 2. —Another, K.B— (imbecile), act. 6, said to be normal up to 3 years,
when she developed epileptic fits which continued ever since. One aunt died
insane. Another aunt was epileptic and paralysed. She herself shows evidence of
left hemiplegia and drags one foot. Superficially this is a secondary ament but
might with equal propriety be regarded as primary.

Case 3. —Another case, I. B— (imbecile), developed normally up to 6 years of
age, when she had a fall. Later minor epilepsy supervened, which gradually
merged into major attacks. She exhibited symmetrical malformation of the
hands, vis., the little finger and the thumb of each hand were remarkably short.
The index was nearly as long as the middle finger, and the ring finger, instead
of being next in length to the middle finger as is normally the case, was much
shorter than the index. Further, she had a symmetrical cubitus valgus, and signs
of right hemiplegia.

History: Father drank. Maternal uncle, set. 38, is an epileptic and cannot
work. Paternal grandfather had epilepsy up to 40 years of age, and died of
dementia aet. 72.

Such a case, one would imagine, would come under Tredgold’s definition of
" Delayed primary amentia.’’

Case 4.— Case, L. 1 — (imbecile), has never talked. At 3 years of age had a
right-sided hemiplegia. Went to bed all right, woke up with loss of use of right
arm and leg. Recovered use of leg to some extent but was unable to walk for six
months. Has had one or two similar attacks since. Has had “fits” of some
kind all her life, chiefly clonic spasms and very frequent, also typical epileptic
seizures of major type. Present type post-hemiplegic chorea affecting right side
and head. Walks with limp, right arm is flexed and contracted. Bilateral
talipes equinus, scoliosis of spine, genu valgum of right side.

Family history. —(1) Father, aet. 41, lately in asylum seven months. (?) Manic-
depressive insanity. (2) Brother died, aet. 2, of convulsions. Mental defective.

(3) Father's brother has been ill for four years—some form of brain disease,
nature unknown. (4) Mother's uncle died, aet. 34. Feeble-minded. Good
example of combined type.

Case 5.—M.A.H—, walked at 3 years, began to talk at 3. Had “ menin¬
gitis ” twice, once at ij years, again at 6. Said to have lost use of legs at the
second attack. At the age of 8, epilepsy developed. Fits have continued
up to present age (9), (serial type, occurring about once a month).

Description. —Notably anaemic. Head hydrocephaloid and globular in shape.
Left internal strabismus. Thorax much deformed. Scoliosis of spine. Double
genu valgum. Aortic incompetence, patellar reflex is present slightly. Apart
from above, no stigmata.

Family History. —(1) Mother was epileptic; fits set in about menopause.
Severe major type. (2) Maternal grandfather, died aet. 70. Epileptic all his life,
no mental impairment. (3) Sister, set. 30, has strabismus and is mentally retarded.
Stays at home. (4) Sister, aet. 16, mentally retarded, stays at home.

The two sisters referred to have never gone out to work, and though not
examined in detail were obviously subnormal in intelligence.

This also is a good example of the mixed or combined type.

Case 6. —A. H—, talked at ordinary age. Not thought to be backward. At
3 years of age had illness described as “ congestion of the brain ” during which
he had convulsions, which have continued ever since, but are now infrequent.
Mental defect said to date from this illness. Never recovered speech and did not
walk for a year after. Present time : Marked paresis of upper limbs and double
genu valgum. Finger-joints are lax and hyper-extensible. Teeth gapped. Fits
have decreased in severity and frequency—average about one per annum.

Family History. —Child illegitimate. (1) Mother, epileptic and very nervous.
(2) Maternal grandfather epileptic. Fits as a boy, decreasing in severity as he
grew older. Died aet. 65. Cerebral softening. (3) Mother’s children by another
father: (1) Son, aet. 28, in asylum, ? mental defective or insane. (2) Son, ait.
20, well. Has had “brain fever” twice. (3) Son delicate, stammers, *t. 18.

(4) Son, died aet. 10 months, convulsions. “ Was born blind.”

Here, though the history is imperfect, a decidedly neuropathic strain is evident-

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The primary character of the defect is evidenced further by the presence of stig¬
mata. Good example of combined type.

Cases might be multiplied indefinitely, but the above are fairly typical
and are sufficient to show the artificiality of the distinction between
primary and secondary type as usually defined. The fact is, one
encounters every degree and variety of combination of the primary and
secondary factors, ranging from a comparatively pure primary type in
which the inherent defect is the outstanding feature, to the type in which
it may be almost if not quite excluded. Moreover there is reason to
believe that the tendency to develop toxic inflammatory or vascular
affections of the cerebrum or meninges is considerably greater in
members of neuropathic families than in normal individuals. At any
rate one is impressed by the frequent occurrence of such affections in
the family history of aments, whether associated or not with normal
•development prior to such attack. The coincidence of similar
affections in other members of the same family, the frequent associa¬
tion with insanity, epilepsy or amentia, as shown in the direct or
collateral lines, suggest more than a chance relationship between
the two.

Similarly with regard to epilepsy as a causative factor. Epilepsy
itself being the expression of a primary neuronic defect ( s )—even
recent metabolic theories do not traverse this point of view,—it
seems rather absurd to distinguish a type of amentia as epileptic
amentia, meaning by that secondary to epilepsy. Again it is only a
question of degree, and such cases may be regarded as primary aments
“at the second remove.” For example, where there is a definite family
history of neuropathic affection, including perhaps epilepsy, and where
epilepsy develops at some period during childhood, it is difficult to
exclude a primary defect of the nervous system, even though mental
defect as such may not have been manifest before the onset of fits. On
the whole, a broad division of cases into two main types— viz. (i) cases
which have a decided neuropathic strain as shown by the family
history, and (2) cases which do not—would prove more useful than the
present one of primary and secondary.

It must be remembered in this connection that the presence of
stigmata is only useful in so far as it implies injury to the germ-plasm
or to the foetus, but this, as a recent writer (3) suggests, may be due, not
to primary defect, but to constitutional disease, and especially to syphilis.

If this contention is correct, many of the cases hitherto regarded as
primary in origin will eventually come under the category of secondary
amentia. Further, when one considers the cases of Mongolism and
certain other types associated with a condition of infantilism and hitherto
included in the primary group, which are probably dependent on
some disturbance of function of the endocrine glands, it is evident that

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259

many other cases which satisfy the present definition of primary amentia
will eventually have to be relegated to the secondary group.

Relationship of Amentia to Epilepsy.

Of the 200 cases dealt with, no less than 58 (or 29 per cent.) have
suffered from epilepsy at some period of their lives, which differs very
little from Sherlock’s (4) figures. Out of a total of 1,600 mental defec¬
tives examined, this writer found 466 (or approximately 29 per cent.)
epileptics.

As might be expected, the fits, though broadly designated epileptic,
included all known types, viz. major, minor, Jacksonian or focal,
nocturnal, diurnal, or combined, and occurred singly or serially, or
occasionally as a status epilepticus. In a certain proportion of cases the
fits started at the second or third year of life, and diminished in
frequency and severity as the child grew older, in many cases ceasing
altogether. In a small proportion of cases the fits increased in severity
with the age. In a considerable number epilepsy started with an acute
febrile illness, in which the child became more or less comatose, and
which left it with a monoplegia, paraplegia, or hemiplegia, and gross
mental deterioration. In most of the cases the mental defect was dated
from and was attributed to the febrile illness, and clinically they would
come under the class of secondary amentia. Some of these gave a
subsequent history of Jacksonian or focal epilepsy affecting the paralysed
or paretic limbs, with gradual transition into ordinary major attacks.
It should be mentioned that a considerable proportion of the cases
gave a history of infantile convulsions gradually merging into true
epileptic attacks.

Considering the large proportion of the total number examined in
which fits occurred some time in their career, the number in which
epilepsy could be definitely assigned a causative role was negligibly
small. In by far the larger number, epilepsy was merely an accompani¬
ment, or occurred in conjunction with amentia as a sequel of gross
brain disease.

Tredgold (5), it may be remarked, in his series of cases, found that
not more than 3^5 per cent, of aments owed their defect to epilepsy,
this being an approximate estimate.

Apart from the fact that at the time of examination (usually from the
ninth to tenth year in my series) the fits had often ceased, or were at
least more infrequent; the characteristic appearance and features of
idiopathic epilepsy were notably absent, viz. the mental hebetude, slow
mental reaction, so-called epileptic facies, and dull, torpid expression.
In short, the clinical picture presented, however diverse in detail,
conformed rather to the ament type than to the chronic epileptic. It
was notable that in a few isolated cases in which one would infallibly

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have diagnosed epilepsy without any knowledge of the previous history,
the fits had supervened comparatively late (at or about puberty).
Moreover the history shows a fair development of intelligence up to the
onset of the fits, followed by progressive deterioration and loss of such
mental functions as had been acquired.

Although, as has been stated above, the causal relationship between
epilepsy and amentia is comparatively negligible, the close association
between the two conditions is of such universal recognition that it calls
for further discussion.

The following analysis shows the distribution of epilepsy in relation
to the three main classes of aments. There were no cases amongst
moral imbeciles.

For purposes of comparison, the corresponding percentage distribution
is shown for the whole number of cases examined.

Epileptic.

Aments.

Feeble-minded

J 3

2 2 ’4 per cent.

• 75

37'5 P er cent -

Imbeciles .

60-3 „

. 103

51*5

Idiots .

I 7'3

Moral imbeciles .

—

' >>

2 ’5

Total .

IOO’O „

200

IOO’O

It will be noted that the incidence of epilepsy amongst the three
types of aments is relatively higher amongst the imbeciles and idiots
and lower in the feeble-minded than one would expect if all the types
were equally affected. Moreover the disparity is greatest in the case
of the idiot class, the percentage of cases having epilepsy being more

than double as many as there would be on the basis of an equal
distribution. This is shown more clearly in the following analysis,
which shows the proportion in which epilepsy occurs in each group :

Total number of idiots
examined.

Idiots with epilepsy.

Percentage.

. IO

59 '°

Total number of imbe¬
ciles examined.

Imbeciles with epilepsy.

Percentage.

103

340

Total number of feeble¬
minded examined.

Feeble-minded with
epilepsy.

Percentage.

1 7‘3

These figures may be compared with Tredgold’s (6), who found that
convulsions occurred in 11 per cent, of the feeble-minded, 42 per cent.
of imbeciles, and 56 per cent, of idiots (all institution cases). The
greater incidence of epilepsy amongst the most degenerate types of

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261

aments is, of course, only what one would expect, and is here shown to
increase progressively the lower one descends in the scale of develop¬
ment. This also accords with Shaw Bolton’s conclusions (7), who
found in 94 cases of low-grade amentia 37*2 per cent, of epilepsy as
compared with 189 cases of high grade amentia with 127 per cent, of
epilepsy. Again, he found a larger proportion of cases of epilepsy in
aments with marked stigmata of degeneration than in those without.
It must be borne in mind that the term “ low-grade ” amentia, as used
by this writer, includes all the three types—feeble-minded, imbeciles,
and idiots—and is not limited to the lower grades. Similarly the
“high-grade” aments, as defined by him, comprise cases of mental
disease which do not come within the provisions of the Mental
Deficiency Act, and are not commonly regarded as mental defectives, but
(8) “ which form the connecting link between the mildest type of imbecile
(the mental defective of the non-alienist) on the one hand, and the
ordinary ‘ sane ’ individual of average intelligence and mental stability
on the other,” and which therefore differ only in degree from the cases
here discussed.

As regards the period of onset of fits, in more than two-thirds of
the cases (40 out of 58) the fits started before the age of four years,
and in less than half (32 out of 58) either ceased altogether after a
variable period, or diminished in frequency and severity. As before
stated, the fits are of the most varying type, both in character and in
severity, ranging from a minor convulsion affecting part of the body, to
a typical major fit. Quite frequently there is a history of ordinary
infantile convulsions gradually merging into true epilepsy, or there may
be minor attacks followed by or alternating with major attacks. At
different periods one type or other may predominate; there may be
remissions for a long interval, or a combination of typical attacks with
localised clonic spasms between the attacks. Some cases again are
associated with chorea, athetoid movements, or motor tics.

Perhaps the most striking feature of the convulsive seizures of the
ament is their association with an attack of encephalitis or meningitis
occurring during the first few years of life. Sometimes there is a history
of “fits,” more or less severe, starting in infancy and culminating in a
definite illness which marks an epoch in the child’s career and in the
mind of the relatives, and therefore is generally remembered. (I say this
advisedly, because it is always a difficult matter to obtain a correct
medical history from relatives, who frequently are uneducated and apt
to romance.)

The history is, as a rule, that the child was suddenly taken ill, had a
series of “ fits,” lay unconscious for several days, and subsequently was
found to have deteriorated mentally, not infrequently being paralysed,
and having lost whatever mental acquirements it may have attained.

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Very often, indeed, the mental defect is referred to the illness. Where
there have been no “ fits ” previous to the illness, they generally
supervene, becoming less frequent and less severe as the child grows
older, and frequently, as stated above, ceasing altogether later in life.
Occasionally one gets a history of two or more attacks of this type, each
so definite as to have memorised the date in the mind of the relatives.
Apart from the marked mental arrest which ensues from such an
attack, there is frequently a loss of the power of speech and partial or
complete paralysis of one or more limbs. It is generally recognised, of
course, that encephalitis or meningo-encephalitis occurring in infancy is
one of the causes of secondary amentia. Tredgold, in his authoritative
work (9), describes the underlying pathological process “as either a
lepto-meningitis or a polio-encephalitis (as described by Striimpell), and,
as pointed out by Oppenheim, the latter closely resembles the acute
inflammation which occurs in the anterior horns of the spinal cord.”

On this point Col. E. Farquhar Buzzard, in a recent paper (10), may
be quoted as follows : “ He thought that the medical profession had
never realised that encephalitis or inflammation of the brain was by no
means an uncommon condition. He was convinced from his own
experience that a large number of cases of epilepsy, of mental deficiency,
of hemiplegia, and of diplegia were the permanent results of attacks of
encephalitis occurring in early childhood, many of these disabilities
dating from an illness occurring in the first few years of life, the history
being that a healthy child had been taken ill suddenly with convulsions,
fever, vomiting, etc., and that the diagnosis of meningitis, gastritis, or
teething had usually been made; he thought that this large group of
cases could be properly attributed to the virus of poliomyelitis.” There
is reason, therefore, to believe that such sudden illnesses during early
childhood are due to a definite infection of the encephalon. The
points I wish to emphasise, however, are the following: that unless a
careful and searching inquiry be made into the previous history of the
case the occurrence of such an affection may be overlooked ; that these
affections are frequently preceded by and nearly always followed by
“ fits ” of some type, and are therefore loosely designated as epilepsy;
and finally (for reasons given in an earlier part of this paper) that
aments in general, and especially the lower grades, are peculiarly liable
to toxic and infective affections of the encephalon. So far indeed from
occurring in a previously healthy child, there is good reason to believe
that convulsive disorders which affect aments, whether of the idiopathic
or infective type, attack particularly individuals with a pronounced
neuropathic ancestry, and are largely the physical expression of a
subnormal cerebral development.

An analysis of the cases included in the present series will perhaps
make the matter clear. Of the 200 aments examined, no less than 65

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1920.]

(that is, 32*5 per cent.) had convulsive disorders of one type or another
at some period in their lives. Of these 55 showed on investigation
marked stigmata of degeneration or evidence of a neuropathic ancestry
either in the direct or collateral lines. Frequently both conditions
obtained or were associated with a family history of tuberculosis.

Amentf suffering
from convulsive
disorders.

Aments suffering
from convulsive
disorders and
with neuropathic
ancestry.

Aments suffering
from convulsive
disorders and
showing stig¬
mata.

Aments suffering
from convulsive
disorders and
with tuberculous
ancestry.

Aments with con¬
vulsive disorders
and neuropathic
and tuberculous
ancestry.

Total number,

(32 5 per cent, of
cases examined.)

^00

(64'6 per cent.)

(30'8 per cent.)

(15-4 percent.)

Total number of
aments examined.

Total number of
aments with
neuropathetic
ancestry.

Total number of
aments showing
stigmata.

Total number of
aments with
tuberculous
ancestry.

200

(48 5 per cent.)

126

(63 per cent.)

(27 per cent.)

The lower columns give the total number of cases examined, with the
corresponding figures and percentages for each group except the last.

It will be noted that the percentage of cases with a neuropathic
inheritance is considerably higher in the convulsive group than in the
whole series. As it has been shown above that it is the lower type of
ament (idiot or imbecile) which is more prone to convulsive disorders,
which type is presumably more likely to be the offspring of neuropathic
progenitors, this is only what might be expected. One would expect,
however, on a similar reasoning, that the percentage incidence of
stigmata would be much higher in the convulsive group than in the
general series, instead of which it is very little higher, there being only
64'6 per cent, in the former as against 63 per cent, in the latter. The
disparity in the figures may partly be accounted for by the fact that
the criteria as to what constitutes stigmata was not quite the same in the
two groups of cases. The convulsive group, for instance, included a
number of cases of encephalitis with secondary paralysis and contractions.
These were not included as stigmata. In the general group the number
showing stigmata was swelled by the inclusion of some such cases.
The differentiation between physical anomalies due to injury and mal-
development of the germ-cell and those due to gross cerebral disease
occurring after birth is admittedly difficult, and the fact referred to
would in any case only partially explain the disparity in the figures
mentioned above.

One must guard against attributing to the figures too great a signifi-

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cance, but the suggestion offers itself that the form of inheritance which
results in the proclivity to convulsive affections, though neuropathic in
character, may differ in degree and in type from that which results in
those gross anomalies of anatomical structure and of function which
are regarded as stigmata of degeneration. In other words the type of
ament with gross stigmata may represent a lower grade in the scale of
neuronic defect than the one which exhibits convulsive disorders. The
matter will be referred to later when the question of neuropathic ancestry
in general is discussed.

Of the total number of 65 cases, 24 presented evidence both of
stigmata and of neuropathic history, and 20 (32‘8 per cent.) gave a
history of familial tuberculosis. This latter may be compared with the
figures for the whole series examined, viz., 24 per cent., and again with
the percentage of normal children as given by Potts (11) and quoted by
Tredgold, viz., 17 per cent. Of the 20 with a history of tuberculosis, 7
gave no other history, 9 gave a neuropathic history in addition, 2
showed also a neuropathic and an alcoholic strain, and finally 2 dis¬
closed alcoholism as the only additional factor. Altogether 7 cases
gave a history of alcoholism, either alone or complicated by tuberculosis
or neurosis.

Neuropathic Inheritance.

A slight acquaintance with the family history of aments establishes the
prominence and importance of a neuropathic ancestry, and in the
series here dealt with one has a definite history of some form of neurosis
or psychoneurosis in either the direct or collateral lines in no less than
97 cases (48'5 per cent.). There is every reason to believe that this
represents a decided under-estimate of the conditions actually obtaining.
The difficulty of obtaining an approximately accurate family history even
in cases of physical disease is recognised by all inquirers. In the type
of case before us this difficulty is enhanced for various reasons. Firstly,
the informant is himself frequently an illiterate person and often of
subnormal intelligence; secondly, there is a natural tendency to conceal
or gloss over incidents or illnesses which are associated with a certain
social stigma, or at the best an implication of inferiority; and lastly the
history, to be of any value, must go back at least two generations, and for
that very reason is frequently fragmentary, vague and inconclusive. The
figures here given represent then the minimum number of cases with
admitted neuropathic inheritance, either direct or collateral, and
must be read in the light of this limitation. Neuropathic ancestry
here includes not only amentia, epilepsy and insanity, but also such
minor neuroses as chorea, neurasthenia, motor tics, etc., and also cases
exhibiting pronounced criminal or immoral propensities, where there
is no direct evidence of neuropathic affections as such. Alcoholism as

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1920 .]

an antecedent factor is dealt with separately, although it is recognised
that it is in many cases merely an indication of the neuropathic consti¬
tution, and should in such cases be included also under this head.

The figures here given may be compared with the corresponding
figures of various writers. These, as quoted by Tredgold (12), range
from 24 per cent. (Beach and Shuttleworth) to 65 per cent. (Goddard).
Tredgold himself found a neuropathic inheritance in over 80 per cent.
of cases (13). “ In 64'5 per cent, the ancestral conditions took the form

of amentia, insanity, or epilepsy, whilst in 18 per cent, they consisted in
a marked family tendency to paralysis, cerebral haemorrhage or various
neuroses and psychoses.” Other authorities quoted by Tredgold (14)
include Lapage (48^4 per cent, of feeble-minded children in Manchester
special schools with neuropathic inheritance), Dr. W. A. Potts, 45-6
per cent, of children in Birmingham special schools, and a Commission
appointed by the Legislature of Connecticut who found neuropathic
heredity to be the undoubted cause in 65 per cent, of cases.

It may be noted that Goddard(15), in his work “Feeble-mindedness:
Its Causes and Consequencees,” found (1) feeble-minded ancestry in
54 percent, of 300 cases, (2) w $ per cent, which he groups as “Probably
Hereditary,” also with feeble-minded ancestry, and (3) 12 per cent, with
neuropathic ancestry, whose family history shows relatives suffering
from various brain affections, such as paralysis, apoplexy, “ brain
disease ” and the like, epilepsy, insanity (so described), blindness,
deafness, and other neurotic conditions. If all these groups be included
under neuropathic ancestry, the total amounts to 77*3 per cent., which
approximates to Tredgold’s estimate of 80 per cent.

The figures quoted are not strictly comparable. Those for the
children in special schools, for example, include a disproportionate
number of low-grade aments, as in my experience a considerable pro¬
portion prove incapable of being educated even in a special school.
Again, Goddard, in his series, gives particulars of on an average 200 or
more individuals in one family. Tredgold conducted a similar exhaus¬
tive research in the case of 200 individuals. It is probable that the
searching inquiries of these two writers would account for their higher
figures.

Apart from the incidence of a neuropathic history, it must be remem¬
bered in this connection that a calculation of the actual number of
cases with neurotic strain gives only a relative estimate of the impor¬
tance of this factor. It takes no account, for instance, of the number
of individuals with mental affection in a given family, or the degree to
which they are affected. This, of course, can only be shown by
genealogical tables. A family with several individuals suffering from
psychoses or epilepsy has obviously a much stronger neurotic strain
than a family with one such member, but this fact would not emerge

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where the ordinary methods were employed. A proper quantitative-
estimate of the neuropathic inheritance would necessarily take account
of these facts.

Apart from the actual incidence of neuropathic ancestry in the whole
group of cases, it is interesting to study its relative incidence in the-
three grades, viz., feeble-minded, imbeciles, and idiots.

Of the 97 cases showing a neuropathic strain 39 were feeble-minded,.
50 imbeciles, 7 idiots, and one moral imbecile. If the neuropathic
inheritance were evenly distributed through the different grades the-
figures would be: feeble-minded, 36-4; imbeciles, 49^9; idiots, 8‘3 ;
moral imbeciles, 2'4, which is approximately what one finds to be the-
case. If anything the discrepancy in the two series suggests that the
neuropathic factor assumes a greater significance the higher one ascends
in the type of amentia, instead of a lesser as one might expect. It
would be interesting to know whether these findings would be confirmed
if a larger number of cases were analysed.

The moral imbecile class may for this purpose be excluded, as they
are hardly comparable, differing as they do from the other types
qualitatively rather than quantitatively.

Alcoholic Inheritance.

Of the total 200 cases examined only 30 (15 per cent.) gave a
definite history of familial alcoholism. What has been said with regard
to the obtaining of authentic records applies here with even greater
force. Apart from the reluctance to admit an addiction to alcohol,,
there is the personal factor, which varies with each observer, to take
into consideration. Data are frequently vague and difficult to standardise,
and are further vitiated by the varying interpretations given to the
same data by different observers. Here, again, the number quoted
represents the absolute minimum and may be regarded as a consider¬
able under-estimate.

The numerical incidence of alcoholism in the different groups is as
follows: feeble-minded, 14; imbeciles, 12 ; idiots, 3 ; moral imbeciles, 1.
If alcoholism were evenly distributed through the groups the numbers
would be: feeble-minded, 11*2; imbeciles, 15‘4 ; idiots, 2^5; moral
imbeciles, 75. One finds, therefore, that alcohol as a factor plays a
relatively greater rSle in the case of the feeble-minded and a lesser one
in the case of the imbeciles, whereas in the case of the idiot and moral
imbecile the distribution is approximately proportionate.

Stigmata of Degeneration.

The term “ stigmata,” as here used, includes all those anomalies of
structure and of function which are so frequently found in association

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■'with amentia, as to suggest that they are part of the germinal blight of
which the mental defect is itself only a special manifestation. They
mostly date from birth or from the early developmental period, and do
not include those structural deformities and imperfections which occur
in secondary amentia as the sequelae of gross organic disease of the
cerebrum. The distinction may appear somewhat artificial and in
practice is a little difficult, but in many cases the clinical picture
presented and the definite history of onset enable one to decide as to
the nature of the defect.

Numerical incidence .—Of the total number of aments under review
(200), no less than 126 (63 percent.) present stigmata. In the great
majority of the cases these are multiple in character, and very
few cases are included which do not exhibit more than one stigma.
Their numerical distribution among the four types of aments is as
follows : Feeble-minded, 37 ; imbeciles, 71 ; idiots, 15 ; moral imbeciles,
3. If the stigmata of degeneration were distributed proportionately
through the different types according to the prevalence of each type,
the incidence would be as follows : Feeble-minded, 47^25 ; imbeciles,
647 ; idiots, 107 ; moral imbeciles, 3*1.

It will be seen, therefore, that the number of moral imbeciles pre¬
senting stigmata is approximately what it would be with a proportional
distribution ; in the idiot class it is much greater (nearly 40 per cent.),
in the imbecile class it is a good deal greater (9‘4 per cent.), whilst in
the feeble-minded class it is much less (21 '7 per cent.). In other words,
excluding the moral imbecile class, the incidence of stigmata shows a
steady rise as one passes from the higher grade to the lower grade
ament. This accords with the findings of most writers on the subject,
who agree in regarding the presence of stigmata as a measure of the
degree of neuronic degeneration.

Character of Stigmata.

The anatomical anomalies encountered may be classified as follows:

(1) Variations in the shape of the external ear. —(a) Asymmetry of the ears:
This is perhaps the commonest anomaly met with, and is almost invariably
associated with bilateral deformity. That is to say, one rarely finds that either ear
approximates to the normal. Where both are deformed, the deformity is greater
on one side than the other, or is of a different type. In my experience asymmetry
of the external ear is more frequent than gross deformity and has at least as great
a significance.

(hi) Abnormally shaped ears : These include ears which are too large or too
small relatively to the size of the head, ears which project laterally, and ears whose
abnormality consists in variations in the shape and development of the various
folds and hollows which constitute the normal contour. Perhaps the commonest
deviation is in the helix, which may be hardly developed at all, resulting in a thin-
edged ear, especially at the tip. Again, the incurved helix may be compressed or
flattened on itself, and when this is the case the compression or flattening is rarely
equal on the two sides. This represents the commonest type of asymmetrical ear.
Another type commonly met with is the long, narrow ear, where the disparity
between the vertical and horizontal diameters is greater than usual although other-

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wise the ear may be normal. An excessive development of the concha at the
expense of the anti-helix, so that the fossa triangularis, fossa scaphoidea and
the concha become one common cavity is frequently seen. This type of ear in the
writer’s experience usually projects laterally. The lobules may be almost absent,
abnormally large, or adherent to any degree. In one case the scaphoid fossa was
continued as a groove into the lobule, which was not so full and pendulous as usual
The case was a Mongolian imbecile who presented the typical stigmata, the ear
abnormality being bilateral.

(2) Variations in the hard palate. —These include varying degrees of highly-
arched and narrow palates. The great majority of highly-arched palates are also
narrow, the narrowing being much more pronounced in front than behind. In a
majority of cases the narrow palate becomes progressively more narrow as one
approaches the incisor teeth.

In a number of cases there is a sudden narrowing about the level of the first
molar.

In both types there is overcrowding of the canine and incisor teeth. Occa¬
sionally one sees a broad flat palate, where the arching is subnormal.

There was no case of cleft palate in the series.

(3) Variations in the face and jaws. —Prognathism, receding chin, loose gaping
mouths are commonly seen, as also are flattening or absence of the bridge of the
nose. Unusual patency or direction of the nostrils, so that the latter look
forwards rather than downwards, are met in special types. The same may be said
of the radial striae or grooves seen in the lips of the Mongol imbeciles. Close
setting of the eyes, the obliquity of the palpebral fissures of the Mongol and the
presence of the epicanthic fold require mention.

Skin affections of the face, especially dryness or seborrhceic dermatitis, are
unusually common. Adenoma sebaceum is rarely seen and is not necessarily-
associated with mental defect. In a typical case seen by the writer the child, an
epileptic imbecile, had had the disease from three years of age. His mother, a
woman of average intelligence, had also had the complaint from early childhood.
A brother of the patient had epilepsy and was mentally defective.

Asymmetry of the face, so much emphasised by many writers, was rarely
observed in the present series.

(4) Variations in the shape of the cranium. —Craniums which conform more or
less to the classical types, brachycephalic or dolichocephalic, are fairly common,
though as a rule the skull of the defective is much more irregular and asym¬
metrical than in any normal type. Apart from the extreme types, such as
hydrocephalic or microcephalic, the commonest deviations from normal are due to
sub-development of the frontal region—receding and narrow foreheads are the
rule—whilst a sharply rising occiput with practically no backward projection is very
common apart from the typical bullet head of the Mongol. A flattened vault with-
projecting bossy forehead is also seen, though probably due to rickets in many
cases. In a large proportion of aments the cranial capacity is markedly
diminished, though the condition is frequently obscured by bony hypertrophy due
to rickets or syphilis.

(5) Variations in the length and shape of the phalanges. —Abnormal shortness
and stumpiness of the fingers as well as incurving of the little finger have been-
described among the stigmata found in aments, but the subject has hardly received
the attention it merits. It may be remarked that in the normal individual there is
a fairly constant relationship in the length of the digits, the second finger being the-
longest, the ring finger being slightly shorter, the index coming next, and the
little finger being the shortest, the thumb of course being shorter than any of the
fingers. Normally the tip of the little finger extends to the last interphalangeal
joint of the ring finger. In a considerable proportion of aments the little finger
and thumb are relatively much shorter than in the normal hand. Frequently the
tip of the little finger does not reach beyond the centre of the second phalanx of
the ring finger. An abnormally short little finger and thumb frequently occur in
association, and in practically all cases the abnormality is bilateral and symmetrical.
Not infrequently, too, one finds an abnormality in the relative lengths of the other
fingers. In a case in point there was abnormal shortness of the little fingers and
thumbs (bilateral and symmetrical). The middle finger as usual was the longest,,
the index came next, and the ring finger third in length. In fact the ring and

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index fingers were transposed as regards their relative lengths. In this case it was
noteworthy that the mother’s hand showed an identical abnormality of the little
finger and thumb, but the relative lengths of the other three fingers were normal.
The abnormality was identical on both sides in both mother and child. As has
before been mentioned, the abnormal shortening of the little finger is frequently
associated with pronounced incurving. Similar variations are found in the length
of the toes, though the relative lengths of the digits are not so fixed or constant in
the normal individual as in the case of the hand. Instead of a gradually tapering
off in length from the great toe to the little toe, one sometimes finds two or three
toes of approximately the same length, or the normal disparity in the size of the
great toe and the rest much less evident than usual. Another not uncommon
abnormality is for one toe to be out of alignment with the rest, giving the
appearance of two toes of the same length. A partial syndactylism is not un¬
common, a partial polydactylism is more rarely seen, and in these and in all the
other abnormalities described the condition as a rule is symmetrical. Partial
syndactylism, or a setting of one toe out of alignment with the others, is not
uncommon in normal individuals, and in all cases observed the condition was
symmetrical. Moreover it usually occurs as an isolated phenomenon and not in
association with other stigmata as in aments.

Hyperextensibility of the joints of the hands and fingers is so common as only
to require mention. Apart from modification in the relative lengths of the fingers a
variation in the absolute length of the digits is very common. A short squat hand
with thick stubby fingers, poorly developed nails, atrophy of the muscles, and
flatness of the thenar and hypothenar eminences resulting in a simian hand have
all been described and are of common occurrence. In short, one rarely sees a hand
normal in shape and contour in the lower-grade mental defective. In the higher
types, as one would expect, the departure from normal is not nearly so evident.

(6) Variations in the teeth. —These have been described in such detail as only
to require brief mention. Overcrowding is the rule where there is a narrow
V-shaped palate. Malposition and eruption at different planes of the alveolus,
abnormally small teeth, rotation of the vertical axis so that the tooth faces
forwards and backwards instead of outwards and inwards and serration of the
edges are the chief abnormalities.

(7) Variations in the eyes. —Close setting of the eyes is fairly common. Re¬
fractive errors are much more common than in normal individuals, though the
present series were not examined from the point of view of the particular defect of
vision. Strabismus occurred in a large percentage of cases. No case of ptosis
was recorded. Iridoplegia was not seen; in most of the cases the pupils reacted
normally to light and accommodation. Eccentric and irregular pupils occurred
but rarely and the same may be said of speckled irides, though Shaw Bolton I
believe regards them as a frequent occurrence in the ament. Rotary or lateral
nystagmus was noted in a number of cases.

(8) Variations in the deep and superficial reflexes. —It is to be remembered that
the cases with a definite history of organic disease of the cerebrum or meninges
with resultant secondary amentia are not included in the present consideration.
This rules out immediately the class of case where one would expect to find
anomalies in the reflexes. Even so the writer has been struck by the variations in
response in both deep and superficial reflexes.

The reflexes chiefly examined were the patellar, the plantar, the epigastric,
hypogastric, the cremasteric, and the pupillary reflex. It is not here proposed to
give a detailed statistical analysis of the results obtained; this it is hoped will form
the subject of a future paper.

In the first place it may be said that most of the anomalies relate to the condition
of the superficial reflexes, which, in view of the frequent disorders of ordinary
sensation met with in aments, is not remarkable.

As the integrity of the superficial reflex arc is dependent upon the function of
sensation, it affords indirectly a gauge to the impairment or modification of the
sensory function, especially as the mental condition often precludes one from
measuring the latter by direct methods.

The variations in the superficial reflexes include:

(a) In a fairly large proportion of cases the superficial reflexes are all absent, or
only present to a minimal degree. Generally a diminution in the abdominal and

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cremasteric reflexes is associated with a diminution of the plantar reflex, but there
is no constant relationship between the two. When one considers the activity of
the superficial reflexes in the normal child, the diminished or total lack of response
of the ament assumes a striking significance. This is perhaps the commonest
deviation from the normal.

( b ) In a smaller proportion of cases the superficial reflexes are exaggerated,
though, as in the preceding case, they are not uniformly affected.

(c) The tendency of the reflex to “ overflow” as it were is frequently exempli¬
fied in the case of the cremasteric reflex. In extreme instances of exaggeration,
when the inner side of the thigh is stroked, not only is there a retraction of the
testicle of the same side, but it is accompanied by a sharp contraction of the
abdominal muscles as far as the umbilicus or beyond it, and sometimes involving
both sides. This, by the way, is not peculiar to aments, but is frequently found in
normal individuals. In such cases there is sometimes an extreme degree of
ticklishness, so that a slight stroking of the skin of the abdomen evokes a fit of
laughter as well as the characteristic muscular response.

This suggests that alterations in the superficial reflexes are chiefly due to
changes in the afferent path, and immediately to abnormalities of sensation.
Finally, it may be remarked that gross anomalies in the superficial reflexes are
frequently associated with a normal condition of the deep reflexes.

It is to be regretted that the scapular reflex was not systematically examined as it
generally disappears in the normal child at or about puberty, and a comparative
study of the condition of the reflex in the ament might be expected to yield
interesting results. One’s general impression is that the reflex is not nearly so active
in the ament as in the normal child. Frequently it is altogether absent. The
scapular reflex (16), it will be remembered, is obtained by stroking the skin in the
interscapular region, when a contraction of the scapular muscles ensues. If the
chest-piece of a stethoscope be placed to the back of a child during ordinary ex¬
amination of the chest there will be a sudden sharp bending of the spine towards
the affected side. In the writer’s experience the sensory receptive area is not limited
to the interscapular region but extends as low as the last dorsal vertebra. This
reflex it is, however named, which is mostly frequently diminished or lost in aments.

(9) Modifications in the motor nervous system are so common in aments and
have been described in such detail as to require little more than mention. Some
imperfection in the motor apparatus may almost be said to be the rule in the
lower grade ament. Ranging from a total or partial paralysis of one or more
limbs in the severe types to a mere inco-ordination or handlessness (to use a
graphic Scotticism) in the less pronounced, one meets innumerable and varying
degrees of imperfection and want of adaptation to the normal needs of the
individual. Apart from gross paralysis, the lack of fine adjustment, shown in the
inability to dress or fasten buttons or execute any delicate movements, is strikingly
common. The clumsiness of gait, the frequent occurrence of deformities of either
extremities, the laxity and hyperextensibility of the distal joints, the frequency of
coarse or fine tremors, chronic chorea, motor tics, and habit spasms, all testify to
the presence of some abnormality or imperfection of the motor system. The
effect of emotion or attention in developing or reinforcing a muscular tremor
is very evident. Chorea, motor tics and athetoid movements are often found as a
sequela of hemiplegia or paraplegia, though quite frequently there is no evidence of
such antecedent event. A fine tremor affecting the whole or greater part of the
body elicited on movement and absent in repose is frequently noted.

(10) Gross deformities of the trunk, spinal axis or limbs occur in the over¬
whelming majority of the lower-grade aments, generally as the result of paralysis
in early or intra-uterine life. In view of the frequency of some degree of paralysis,
or paresis of the limbs, this is to be expected. They include genu valgum and
genu varum, pes cavus, pes equinus or equino-varus, and pes valgus. Pes planus,
the commonest foot deformity of the normal individual, is comparatively rare in
aments. Secondary scoliosis of the spine is frequently associated with these
deformities, and kyphosis and lordosis are fairly common. Cubitus valgus or
varus is occasionally seen and when present is bilateral. Rickety curvature of the
limbs and chest deformities are, I think, not more common than in normal in¬
dividuals, and the same applies to the cranial abnormalities due to rickets.

(11) Variations in the external genitalia. —Under or over-development of the

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external genitals are found in a fair proportion of aments. In the males non¬
descent of the testicle on one or both sides is perhaps the commonest anomaly.
In a certain number of cases, on the other hand, the external genitals and especially
the penis are ridiculously large in relation to the size of the body. In some male
cases the bodily contour conforms more to the female than to the male type, the
stature being short and stumpy, the genitals undeveloped or rudimentary, and
there being an excessive deposit of subcutaneous fat throughout the body.
Another feature of these cases is the diminution of the normal curves of the spinal
column so that the back is short and straight. The condition in fact resembles
that found in the so-called dystrophia adiposo-genitalis, although no case was seen
which presented the extreme signs of infantilism exhibited by typical examples of
this disorder. None the less, it is not improbable that these cases are merely
minor examples of what Schafer describes as hypopituitarism (17), and are due to
disease or atropy of the pituitary glands. As the diminution in stature is related
to atrophy of the anterior lobe of the pituitary gland, and excessive fat formation
and deficient sexual development to deficiency of the posterior lobe, it is to be
supposed that in this case the whole gland is concerned. This is merely a sug¬
gestion thrown out, of course, and would, if correct, account only for the bodily
conformation as described.

Similarly, some female aments are characterised by an unusual bony and
muscular development, a bodily conformation resembling the male type with a
notable absence of subcutaneous fat, with the roundness of contour characteristic
of the female. The absence of mammae, presence of hair on the limbs or trunk,
and occasional absence of hair from the pubic area combine to heighten the
resemblance to the male. Such individuals are generally tall, and have a pelvis of
the male type, and unusual length of limb.

In one such case, that of a female, aet. 33, the facies resembled that seen in
acromegaly. The nose and upper jaw were relatively large; the thorax was of the
male type with absence of mammae. There was scantiness of the pubic hair, the
limbs were long and muscular, and there was a marked kyphosis in the dorsal
region and a notable diminution of the subcutaneous fat. She was stated never to
have menstruated. Her mental state was that of a feeble-minded person. This
case may be contrasted with the condition of infantilism discussed above, and the
condition may be attributable to hypertrophy of the anterior lobe of the pituitary
gland so far as the somatic variations are concerned.

Hypospadias and epispadias are occasionally though comparatively rarely seen,
and no case of hermaphroditism was met with in the series.

The above represent the main types of variations in the anatomical
structure found in the series of aments under review, and their signi¬
ficance lies in the fact that though any of them may occur singly in the
normal individual they occur far more frequently in aments, and in the
vast majority of cases are multiple in character.

A Comparison of the Numerical Incidence of Stigmata and
Neuropathic Inheritance Respectively.

As already stated, it has been found that the incidence of stigmata
shows a steady and notable rise as one descends in the scale from the
higher-grade to the lower-grade ament, whereas a neuropathic inheritance
is, if anything, slightly more common in the higher grades of amentia
than in the lower. This perhaps hardly accords with one’s expectations,
and certainly not with the views currently held. Most writers, indeed, on
this and kindred subjects regard stigmata as indicative alike of the
degree of neuronic degeneration and a measure of neuropathic inheri¬
tance, the implication being that one increases pari passu with the other.

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Whether true or not, this view is certainly not confirmed by the findings
of our present analysis, although it is recognised of course that the
analysis of a larger number of cases might yield very different results.

Aldren Turner, for example (18), speaking of stigmata, says—“They are
of immense value as an index of the intensity or degree of the hereditary
predisposition.” Moreover, he finds (19) “ that of 200 cases of epilepsy
42 per cent, presented well-marked evidences of structural stigmata,
although no hereditary neuropathic history could be obtained; while of
those in whom such a history was known, only 24 per cent, showed
stigmata.” He goes on to say (20): “ It is therefore obvious that the.
absence of a family neuropathic history is of little account in face of the
well-marked structural signs of an inherited degenerative disposition
which many of the cases presented. Moreover it is clear that if the
family history could have been probed more deeply, a large percentage
of those with stigmata of degeneration would have made mention of
some inherited degenerative psychosis." Upon which one may comment
that the postulated relationship between stigmata and hereditary
predisposition is by no means established—at least so far as this writer
is concerned.

Special Clinical Types.

(Mongolian and Cretin Imbeciles.')

Two groups of mental defectives, via., the Mongolian and the cretin types, stand
out pre-eminently from the general body by virtue of their strongly marked physical
characteristics and the pronounced resemblance to one another of the individual
members of the class in question. Although the aetiology of the cretin may be
regarded as settled, whilst that of the Mongolian imbecile is still sub judice, the
general resemblance between the two groups is such as to suggest a similarity in
origin, vie., a disturbance of function of the endocrine glands.

Out of the 200 cases examined only 8 were Mongolian imbeciles, whilst 2 were
cretins, all 10 cases being typical examples of their class.

Mongolian Imbeciles (8 in number).

The whole eight were males.

Case i.—C. P—. The child was fifth in a family of five, there being ten years’
interval between birth of patient and the last preceding child. No neuropathic
history. Age of mother at birth of patient 40.

Case 2.—G. F—. Patient was the only child and was born two years after
marriage. Father was “ nervous ” and unstable, and maternal uncle was insane.
Mother’s age at birth of patient 32.

Case 3.—I. B—. Patient was last born in a family of nine. No neurosis in
family. Mother’s age at birth of patient 40.

Case 4.—E. A. G—. Patient was last bom in a family of five. Maternal aunt
became insane at climacteric. Age of mother at birth of child 40.

Case 5.—J. W—. Patient was third child in family of four. Maternal grand¬
father drowned himself (melancholia). Age of mother at birth of patient 37.
Patient was an epileptic and had hypospadias.

Case 6.—N. A. W—. Patient was third in family of three. No neurosis in
family. Age of mother at birth of patient 32.

Case 7.—F. B—. Mental status that of idiot. Patient is eighth child in family
of eight. Father drank heavily for twenty-six years. Age of mother at birth of
child 46.

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Case 8 .—J. G—. Patient is second child in family of four. Father and paternal
grandfather addicted to drink. Age of mother at birth of patient 30.

To summarise, all eight cases were males. In five cases the child was the last
born in the family. The youngest mother was aged 30 and the oldest 46, the
average age of the mother at birth of child being 37I years.

In three cases there was a history of insanity in either the direct or collateral
lines, in two a history of alcoholism, whilst in three there was no evidence of
neurosis.

Although the number of cases was small the evidence would suggest that the
comparatively advanced age of the mother is a probable factor, with its possible
corollary—an exhaustion of the reproductive function ; and secondly that neuro¬
pathic inheritance probably plays an equally important rile. The disharmony or dis¬
turbance of function of the endocrine glands which is now regarded as the essential
and proximate cause of Mongolism may be related to the age of the mother, but
the mode of operation of the neuropathic factor is less direct.

Cretin Imbeciles (a in number).

Both cases were typical examples of cretinism.

Case i. —H. T—, male. The mother was "nervous” and the maternal uncle
was an inmate of the imbecile ward of a workhouse hospital. Patient was the sixth
child in a family of twelve.

Case 2.—A. M. I —, female. Patient was eldest child of six. No history of
neurosis, but maternal grandmother died at 52 “ at the change of life.” Age of
parents at birth of patient was 25. The patient herself, although 16 years of age,
was only a little over 4 ft. in height.

The number of cases was too small to prove anything as to aetiology beyond the
obvious fact of thyroid deficiency.

Tuberculous Inheritance.

Of the 200 aments examined, 48 (that is, 24 per cent.) gave a history
of tuberculosis either in the direct or collateral lines. Tredgold (21)
found a tuberculous history in the families of 34 per cent, of cases
investigated, and quotes Beach and Shuttleworth as finding close upon
30 per cent., Langdon Down 225 per cent., Kerlin 56 per cent, and Potts
43’2 per cent, of defectives as compared with 17 per cent, of normal
children. My figures include tuberculosis of all types, pulmonary,
glandular, intestinal, and tuberculosis of bones, and as in the case of
neuropathic ancestry probably represent a considerable under-estimate
of the actual facts. One is repeatedly struck by the co-existence of
tuberculous affections in several members of the family with insanity,
epilepsy, or mental defect in others. The two strains, the neuropathic
and the tuberculous, are rarely combined in the same individual, but in
extreme cases the distribution is such as to suggest an alternation or
substitution of the two diatheses in different members of a family.

References.

(1) A. F.-Tredgold .—Mental Deficiency, p. 224.

(2) J. Shaw Bolton .—The Brain in Health and Disease , p. 199.

(3) H. Frieze Stephens.—“ The Compluetic Reaction in Amentia,”
Joum. Ment. Sci., October, 1916.

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(4) Sherlock.— The Feeble-minded, p. 261.

(5) A. F. Tredgold.— Mental Deficiency, p. 277.

(6) Op. cit., p. 221.

(7) J. Shaw Bolton.— The Brain in Health and Disease , p. 198.

(8) Op. cit., p. 162.

(9) Tredgold.— Mental Deficiency , p. 226.

(10) “Lethargic Encephalitis.”—Paper read before Med. Soc. of
London by Col. E. Farquhar Buzzard, Brit. Med. Journ., December
,24th, 1918.

(11) W. A. Potts.—Quoted by Tredgold, Mental Deficiency , p. 47.

(12) Tredgold.— Mental Deficiency, p. 40.

(13) Loc. cit.

(14) Loc. cit.

(15) Goddard.— Feeble-mindedness, its Causes and Consequences, p. 437,

(16) Hutchison and Rainy.— Clinical Methods (, Superficial Reflexes).
P- 477 -

(17) E. A. Schafer.— The Endocrine Organs, p. no.

(18) Aldren Turner.— Epilepsy, p. 31.

(19) Op. cit., p. 38.

(20) Op. cit., p. 38.

(21) Tredgold.— Mental Deficiency, p. 47.

(*) The so-called delayed primary amentia, in which there is a latent period of
normal mentality, is after all only a sub-division of primary amentia, in which
the potentiality for normal development is rather greater than in the typical cases
of this group.—(*) “ The co-existence of epilepsy and mental disease is thus of such
a character as to indicate that both conditions are symptomatic of cerebral
.degeneracy” (The Brain in Health and Disease, by J. Shaw Bolton, p. 199).

Anxiety States Occurring at the Involutional Period. (}) By D. K.
Henderson, M.D.Edin., F.R.F.P.&S.Glas., Senior Assistant
Physician, Royal Asylum, Gartnavel, Glasgow.

A widower, aet. 69, was admitted recently to the Glasgow Royal
Mental Hospital in an anxious, apprehensive, excited, restless state.
The history of the case showed that he had come of a good stock, and
that he had been a strong, healthy man. For a period of forty-six years
he had been employed by the same firm of lawyers, and latterly had
been their cashier. He had married twice; there were four children
from the first marriage and two from the second. He had divorced
his second wife on account of her unfaithfulness. In January, 1919,
he resigned his position, sold his home, and made plans to live with
his daughter. Three days after his home and furniture had been sold
he made a determined attempt on his life by cutting his throat. One
month later he was admitted to the Glasgow Royal Mental Hospital.
Following his admission he continued in a state of abject misery, he

(') Paper read at the meeting of the Scottish Division, March 19th, 1920.

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moaned and groaned, wrung his hands, resented any interference, and
was very restless. He realised that he was in a hospital, but his mind was
so occupied by his depressive thoughts and he was so miserable that he
would not assist in a satisfactory mental examination. Physically he
was in poor general health, his pulse was irregular and intermittent,
and he had peripheral arterio-sclerosis. During the next few months
he gradually improved in strength and general condition but mentally
panics of anxious apprehension supervened from time to time, in which
he became self-accusatory, and expressed hopeless feeling as regard his-
prospect of recovery. At the same time he was perfectly oriented, and
his memory, general knowledge, and personality were all well retained.
No particular attempt was ever made at psycho-analysis (his age seemed
to preclude such a procedure), but nevertheless casual conversations
were sufficient to allow him to give expression to his fears, and inci¬
dentally to show where his conflicts and difficulties lay. He complained
of the other patients, said that they looked as if they could tear his
bones out, that they wished to do him an injury, that they slandered
him, that they accused him of incest with his daughter. At this point
he began to defend himself with great warmth and emphasis, and said,
quite unnecessarily, that the only thing that supported him was the
consciousness of his own rectitude, that nothing had been further from
his thoughts, etc. These matters were never argued out with him,
but he was encouraged always to say what he had to say, and eventually
six months after admission he was discharged as recovered.

How is such a case to be interpreted ? Is it sufficient and satisfactory
to think of it as a case of anxiety and depression in a senile suffering
from arterio-sclerosis who recovered mentally as his general condition
improved? 1 do not think this view is helpful in any way. Tb<s inan
of sixty-nine years had determined to break with his lifelong associa¬
tions, and when the time came could not adjust himself to the new
situation ; a depression, not unnaturally, took possession of him and
he attempted his life.

The question then arises as to whether this case was manic-depressive
in type, being one of the so-called “ mixed ” states ? There is still
another view which can be taken. The patient, in addition to his
depression, gave expression to certain complex material which might
bear a close relationship to his anxiety and apprehension and his
righteous self-justification, suggesting involutional melancholia, or
better, the anxiety-reaction type.

I have examined the hospital records for a period of five years from
January 1st, 1915, to December 31st, 1919, and find that as regards
the age-period 40 to 70 years 299 patients—160 women and 139 mea
—were admitted.

The types of mental disorder were:

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Women. Men.

Anxiety states . 65 32

Mania . . .12 6

Manic-depressive .27 11

Paranoid states .26 10

Organic brain

disease 23 69

Dementia praecox
Mental deficiency
Delirium .
Epilepsy .
Psychasthenia .

Women. Men.

3 4

2 2

1 I

— 4

1 —

It will be seen that 65 women, or roughly 40 per cent., and 32 men,
or roughly 23 per cent., had a psychosis in which anxiety in one form
or another was the predominating symptom. The majority of these
were first-attack cases. On the other hand, the manic-depressive cases,
the great majority had had either one or several attacks at a much
earlier age. I might have included in the manic-depressive group the
12 female and 6 male cases of mania, but I have considered it better
to keep them separate so as to make the contrast between the depressive
and maniacal attacks occurring at this period of life more striking. The
fact that 69 men and 23 women showed symptoms of organic brain
disease is only what one would expect. None of the other groups call
for any special comment.

Of the anxiety cases, 59 per cent, women and 56 per cent, men either
recovered or definitely improved as follows :

Women.

Recovered.26

Relieved .

Not improved .

Under treatment
Died .

Men.

4
7

6S 32

These statistics go to prove that anxiety states occurring at the
involutional period are a relatively frequent type of mental disorder,
and furthermore, that anxiety is a benign type of reaction. That being
so, it would be profitable to inquire more closely into the mechanism
of the disorder as helpful to treatment.

It is generally accepted that the involutional period, as the name
implies, is a physiological epoch when the body-chemistry commences
to undergo certain changes. It is the period of life when the sexual
glands begin to lose their functions, the bodily processes to decline,
and the organism to fail. The person loses his vigour and elasticity;
he can no longer adapt himself to new events and situations of life
which entail stress and strain and give rise to careful thought, and,
maybe, anxiety. Just as the future looms large, so also does the past
assume a proportion which it never previously possessed, and “ what
might have been ” gives cause for reflection. We thus conceive the

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involutional period as a time of life when new adaptations have to be
made, and to those unfortunately possessed with unstable nervous
systems we can readily understand how fraught with danger such a time
is. Trifles, petty worries, and difficulties of all kinds which formerly
hardly gave a moment’s thought now seem overwhelming, the prickings
of conscience are in the foreground, the sins and misdemeanours of
the past assume tremendous proportions, feelings and thoughts which
have been carefully repressed and apparently forgotten come uppermost,
and often find expression in crude sexual beliefs and ideas. Such a
conflict of instincts soon brings about a more definite psychic state,
with anxiety, fear and apprehension as the striking symptoms. Insomnia
becomes distressing, delusions are freely expressed, and attempts at
suicide are not uncommon. With all this the personality of the
individual remains practically intact, the memory is good, and the
sensorium is relatively clear. Kirby, in his discussion of anxiety states,
goes a step further, and attempts to differentiate the following groups:
(1) Cases showing a simple form of anxiety or general uneasiness,
apprehensive anticipations, with or without ideas of sin ; (a) a severer
form showing anxiety with fear, perplexity, and allo-psychic concepts.
(3) cases presenting the sensory somatic complex, abnormal bodily
sensations, hypochondriacal trends, and feelings of unreality; (4) cases
developing with arterio-sclerosis.

I will now consider the case I have reported in the light of these
facts.

It has, I think, been definitely proved that peripheral arterio-sclerosis
can exist apart from cerebral arterio-sclerosis, so that in a given case
where peripheral arterio-sclerosis is present we should hesitate before
coming to the conclusion that the mental condition is arterio-sclerotic
in nature. Arterio-sclerotic brain disease is an entity accompanied
by such definite physical and such marked mental symptoms that
we should never confound it with such conditions as anxiety-states.
Transitions must and undoubtedly do occur, but the diagnosis of
arterio-sclerotic brain disease should be limited to those cases with a
history of headache, vertigo, convulsive attacks, and a defective memory.
It is because of the absence of these pathognomonic symptoms that
I have kept the case described apart from the arterio-sclerotic group.

The second and more difficult point is the relationship of such a case
to the manic-depressive reaction type. When Kraepelin differentiated
between manic-depressive states, dementia prsecox and the other
functional groups he kept apart cases of melancholia occurring at the
involutional period, and reserved for them the term “ melancholia.”
A few years later one of his pupils, Dreyfus, reviewed some eighty of
Kraepelin’s cases, and sought to prove that these were really manic-
depressive cases. Kraepelin accepted and concurred with the findings

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of Dreyfus. Dreyfus made a special point of proving that cases of
pure depression and excitement were not so common as had been
thought, and that the involutional cases corresponded to Kraepelin’s
mixed group of manic-depressive. He stated also that these involu¬
tional cases had the same good prognosis as the manic-depressive cases,
and that the prognosis only became unfavourable when arterio-sclerotic
brain disease occurred. The recovery-rate in his group of cases was
66 per cent ., and in one-third of the cases the duration was over three
years. Kirby, to whose review I am greatly indebted, concluded by
saying: “ In a number of cases the manic-depressive symptoms were
plainly in evidence, the cases having been improperly placed with the
melancholias. In a considerable number of other cases the author’s
conclusion that manic-depressive symptoms were present is based on
extremely meagre data.” I am heartily in agreement with Kirby’s
criticism, which is supported by certain definite findings.

From the point of view of aetiology it is striking to find how
frequently in anxiety states mental factors, e.g., the death of a near
relative, financial and business worries, unfortunate home conditions,
the breaking up of the home, etc., are assigned as the precipitating
or exciting cause. On analysing my cases the causes were as follows :

Women. Men.

Mental.37 . 23

Physical. 61 4

Combined.14 ' l “! 5

65 3 *

Thus in 57 per cent, women and 71 per cent, men the setiological
factors were mental, whereas physical factors were only of importance
in 21 per cent, women and 6 per cent. men. William Mabon, in his
A Study on the sEtiology of Insanity , found that in manic-depressive
insanity the percentage of mental and physical causes was about equal,
whereas in the involutional cases 47 per cent, were of psychic origin,
34 per cent, of physical origin, and 17 per cent, were due to these
combined. These statistics have been confirmed by others. The
manic-depressive reaction, on the other hand, is much more of the
nature of a constitutional disorder.

Another point which might be brought into consideration is the fact
that in rural districts the percentage of involutional cases is much
greater than in metropolitan areas. Meyer has ventured the suggestion
that this is possibly due to a narrower mental horizon. Whether
or not his view is correct is not unworthy of study.

These two types—anxiety states and manic-depressive—may also be
distinguished symptomatically. In anxiety states fear and apprehension
dominate the picture, and the feelings of fretfulness and uneasiness

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and the expression of somato-psychic delusions are all very characteristic.
The typical depression of manic-depressive insanity is much more of
the sad slow retarded variety with a subjective feeling of difficulty in
thinking. I do not mean to imply that this differentiation is
absolutely clean cut, but in the main it seems to hold good.

The course of the disease is also different in the condition under
discussion. Anxiety states as a rule run a much more acute course,
the danger of death is greater, but again taken as a whole the prognosis
is better than in the slow, depressive states occurring in manic-depressive
insanity after the age of forty years. In both conditions there is a
tendency to recurrence, but when an anxiety state does recur it is
always in the form of another anxiety attack. Anxiety states run true
to type, whereas in manic-depressive states the subsequent attack may
either show excitement or a depression. The fact also that anxiety
states do not as a general rule develop until the involutional period
seems to point to these patients having less instability than the manic-
depressive types. For the reasons enumerated I feel we are justified
in not subscribing to the Dreyfus-Kraepelin doctrine. On the other
hand, we are more or less forced to recognise the prevalence of a group
of cases which may be called the anxiety reaction type. It is for
these reasons that the case reported cannot be grouped with the
manic-depressive psychosis.

What then ; ts relation to the anxiety neurosis as described by

Freud. It oeen urged that there is a very intimate association

between the sex instinct and the emotions of fear, and Freud, in his
investigation and description of the anxiety neurosis, states that the
causes of this disorder depend on the fact that the sexual life of the
individual had not been satisfied. Morbid anxiety was to be held as
synonymous with unsatisfied love. In addition, Freud states specifically
that in certain cases no aetiology can readily be determined, and in
such cases he believes that it is usually possible to demonstrate a
marked hereditary taint. The clinical picture of this state is described
as one of general irritability with auditory hyperaesthesia, anxious
expectation, and often palpitation with cardiac irregularity, disturbance
of respiration, profuse perspiration, diarrhoea, trembling, vertigo, etc.
As a result of his clinical experience and of the analysis of his cases
Freud formulated the theory that these “anxiety” symptoms were due
to somatic excitations which could not find a suitable outlet, and Jones
has summed up this view by saying that in the anxiety neurosis the
mechanism of the disorder consists in there being “ an excessive afferent
excitation with deficient efferent outflow.” In the anxiety psychosis
occurring at the involutional period the clinical picture is essentially
the same as in the anxiety neurosis, but the conduct of the individual
is less under control; the mechanism of the disorder seems to be
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essentially the same. The old gentleman of sixty-nine years whose case
I have reported no doubt had been troubled with morbid, incestuous
thoughts and had doubted his capacity to deal with them. This was
proved by the fact that during his psychosis he frequently referred
to the topic with great affect, and rarely, if ever, did he mention the
breaking up of his home and the resignation of his position. His
psychosis, in other words, acted as a safety-valve, because it allowed
him to give expression to those doubts and fears which in normal life
he had so carefully repressed.

Another case in point is the following: A married woman, *et. 53,
who is in a state of anxious apprehension, is tearful, feels that she will
never get better, that the hospital is not the proper place for her, that
she should be given another chance, and that if she were she would
exert more will-power and keep a better grip on herself. This lady’s
husband is a marine engineer who is constantly away on long voyages,
and is only at home for a few days between trips. She has one child, a
boy, who is now nineteen years old. Until this boy was sixteen years old,
the patient devoted herself to him, learned the school subjects with him,
and identified herself with him in every way. At this stage difficulties
arose. The boy began to emancipate himself, and to form friendships
and interests outside the home. This was the time that the patient’s
psychosis developed, and during the next three years she was in and out
of several mental hospitals. The patient is refined, sensitive, and lady¬
like ; on the other hand, her husband is a commonplace man. There
seems to me to be no doubt that this woman’s love-life has been
unsatisfied, and that she attempted to compensate for this by devoting
herself entirely to her boy. She has herself expressed the situation by
saying, “ It would have been so different, doctor, if I had only had a
daughter.” It is evident that when her method of sublimation was
taken from her and she was thrown on her own resources she failed
utterly to face the situation, and her repressions and difficulties gave
place to anxiety and apprehension.

The psychosis in the first case went so far that all barriers were
broken, and the patient got relief from his tension by the expression of
his inmost thoughts, but in the second case the only thing one can hope
for is that a satisfactory compromise may be effected.

The analysis of these two cases seems to prove that the climacteric,
per se, and the precipitating mental and physical factors act by lowering
the resistance of the individual, and give a chance for the submerged,
repressed and “forgotten” trends to come to the surface; they have no
specific action whatever. The great difficulty with involutional cases is
that they have reached a time of life when they have lost their elasticity;
it is no longer easy for them to unburden themselves of their conflicts
and troubles, and for the most part they are totally unconscious of

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the connection between their repressed instincts and their anxiety
symptoms.

We should learn from these cases of anxiety not to think of them too
closely in terms of mental and physical factors, and of symptomatology
and classification, but rather regard them from a broader, biological
standpoint. We must try and fathom their real difficulties, how they
have attempted to meet them, and how we can assist. By dealing with
these cases in this way we have something definite to work with, we
gain a more vital and stimulating interest in them, and we shall come
to recognise that symptoms of fear and anxiety are unhealthy methods
of meeting instinctive difficulties. It is these anxious, uneasy, fretful
types of patients who are always so ready to explain their troubles on
the basis of their environment, and never seem to realise that it is they
themselves who are at fault. They cannot own up to the actual situa¬
tion and hang their anxiety on any peg that offers. For instance, one
of our patients, at present in a state of great anxiety and fear, and
addicted to masturbation, told me that I had murdered her, had destroyed
her body, and that only her face and hands were left. The fact is that
she herself is afraid that she may have injured or destroyed her body by
her auto-erotic habits, but instead of meeting the situation honestly she
makes the doctor the scapegoat and accuses him of murdering her, i.e.,
of destroying her body. A school teacher, set. 48, reiterates over and
over again that she has killed her sister. The facts are that several
months ago her sister died in a general hospital following an opera¬
tion for ovarian cyst. The patient’s sister had confided to the patient
that her abdomen was beginning to swell, but both sisters had been too
prudish to consult a doctor until the swelling had become very notice¬
able. The patient now blames herself for not having acted more
promptly, but a superficial analysis shows that she has simply seized
hold of her sister’s death as the explanation of her anxiety because she
is quite unable to meet her deeper instinctive difficulties. It is no easy
or pleasant task to attempt to delve into the inner life of a maiden lady
of fifty years or thereabouts, and as a general rule I would not advocate
it, but I do think that we should make some attempt to give such
patients a better understanding of themselves, and of what their illness
means to them. It is quite possible in most cases of the anxiety-reaction
type to give the patient a general explanation in regard to how such
attacks often originate from factors which he or she has been unable to
adequately meet, and that therefore it is important that the whole life-
history of the individual should be discussed. Just as a tubercular focus
may light up when the general health of the individual becomes lowered,
so also may repressed ideas again assert themselves and act as sources
of irritation. “ Where there is pus let it out ” is as much a truism in
mental disorders as in general medicine. To that end it is important

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The most striking facts revealed are that whereas in general paralysis,
excluding the effects of old inflammations, spermatogenesis is active, and
in many cases very active, and the degenerative changes in the brain the
outcome of spirochastal poison, in dementia praecox there is invariably
regressive atrophy of the seminiferous tubules, and the changes in the
brain are a primary nuclear degeneration.

There is an intimate relationship between the adrenal cortex and the
reproductive functions, and Mott found in four male cases of well-
marked dementia prsecox that the adrenal cortex was narrowed
and lipoid much less than in cases with other mental diseases. One of
the functions of the adrenal cortex is to provide lipoid needed to build up
myelin, but it also stores lipoid, which can be set free to form anti¬
toxins (Elliot), and it also provides a constant supply of raw material to the
testes for formative nuclear activity. It follows that any breakdown in
the lipoid-supply mechanism, especially in early life, would affect the
nucleus of the neuron and create a deficiency in the organic phosphorus
in the nerve-cell and a loss of vital resistance to infective diseases.

It is obvious that, as regards dementia praecox, further investigations
in this direction may have a profound effect on the nosology of this
disease, and Sir Frederick Mott’s further communication, as regards the
correlation of the morbid biological changes in the testes and those in the
central nervous system, will be awaited with considerable interest.

(') “ Normal and Morbid Conditions of the Testes from Birth to Old Age in 100
Asylum and Hospital Cases” (Brit. Med. Journ., November 22nd, 29th, and
December 6th, 1919), by Sir F. W. Mott, K.B.E., F.R.S., etc.

Part II.—Reviews.

The Fourth and Fifth Annual Reports of the Board of Control , 1917-
1918.

The exigencies of the great war rendered it impossible for us to review
the annual reports of the Board of Control for the years 1917 and 1918 at
the usual time. The war interfered profoundly with all established
practices, and it lies to the credit of the late Dr. Drapes, who with
great devotion conducted the Journal almost single-handed during the
military service of the senior Editor, that the organ of the Association
was not even more attenuated— conquiescat in pace.

For many years past, those sections of the Board’s report dealing
with the incidence of insanity, and the recovery and death-rates,
have been the matters of outstanding interest, and for this reason
the main subjects dealt with in our annual review. It has never been
an easy task to criticise the Commissioners’ carefully worded con¬
clusions, and thus the specious complaint made in our review of the
report of 1916 regarding the cutting-down of the number of tables in

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Part II from thirty-eight to fourteen is explainable, if not excusable.
Our attitude could well be likened to that of the Israelite when asked
to make bricks without straw. In view of the additional important and
weighty matters dealt with in the reports for 1917 and 1918, we have no
grounds to renew the complaint, and it can be noted, without regret on
our part, that the Commissioners are unrepentant in this matter and
continue in their course of economy.

Number of notified insane. —The rate of decrease which com¬
menced with the onset of war continued during the years under
review, being for 1915, 3,159 ; 1916,3,278; 1917,8,188; 1918,9,138;
total decrease, 23,763, instead of an increase of 32,767 to be expected
under ordinary conditions. The total number of notified insane on
January 1st, 1919, in England and Wales was 116,703.

Admissions. —The rate of decrease on the previous year of patients
admitted to institutions and single care was 5‘2 per cent. (8'6 per cetit.
men, 2 - i per cent, women), and io'9 per cent. (12T per cent, men, 9'2
per cent, women) for 1917 and 1918 respectively, the actual numbers
being: 1917, 19,632; 1918, 21,765. During 1918, there was an in¬
crease and not a decrease, as in 1917, in the percentage proportion
of male and female admissions of o'5 on the proportion of males
obtaining in the previous year.

Discharges .—The recovery-rates for 1917 and 1918, calculated upon
the total admissions, were respectively 31’33 per cent. (26^82 men,
35’i3 women) and 27 - i4 (2276 men, 3o'9i women). That for 1918
is the lowest ever recorded.

Deaths. —The abnormal increase in the death-rate continues. Calcu¬
lated on the daily average number resident it was for 1917 16 86 per
cent., and for 1918 i9‘56—respectively 6 - i 1 and 7 89 above the percentage
for the decennium.

It has been said it never rains but it pours, and these surprising
figures call for careful examination and inquiry as to whether their face
value reveals the true state of affairs. Do they really mean that
during the war fewer people became insane, that the insanity which
occurred was less recoverable and more fatal ? The answer to the first
question is almost certainly in the negative. It is obvious that if the
number of those admitted to certificate is less, and if more die, those
remaining in confinement and single care will decrease. Certifiable
insanity and mental disease are not synonymous terms. Normal con¬
duct or normal relationship to environment attains a higher standard
as progress is made in the social life of the people, with the result that
disordered mental states more readily enter the domains of certifiable
insanity. A retrograde movement would have just the contrary effect,
other conditions being equal. Can it be said that the universal social
disintegration, the necessary concomitant of a world-wide contention,
has kept up the standard of normal conduct ? A mere perusal of the
daily newspapers seems to be quite convincing that the contrary has
occurred. Heroic efforts undoubtedly have been displayed, but have
been accompanied by a degree of social dissolution. We venture to
suggest that, apart from the beneficial effects of less unemployment and
higher wages, also the restrictions on the consumption of alcohol, the
decrease in the admissions does not indicate a decrease in insanity, but

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has been due to fewer people having been certified, owing to the public
becoming less sensitive to abnormalities and vagaries of conduct, and
also to the partial suspension of the scavengery of the population
by the lunacy authorities; and that lunacy, moral and sex degeneracy,
perversion, etc., are merely dammed back and waiting to be
garnered. We suggest a rich harvest sooner or later, and it is to be
hoped that, in the meantime, the administrative machinery and the
methods of classification, care and treatment will have been reconstructed
on the enlightened lines so urgently desired, and that the accumulation
will not be packed a capite ad calcem in mental hospitals as in the past.
The half-baked lunatic and higher-grade imbecile when at large are always
a source of grave danger, especially during times when even steady
politicians and social workers tend to become infected with anti-social
and revolutionary crazes, and the sooner this cleaning up is effected the
better in the interests of public tranquillity.

The lessened recovery-rate is due to the cases being admitted at a
more advanced stage of their disease, and also no doubt to the same
causes which increased the death-rate, such as the diet restrictions and
the impairment of nursing facilities. There may also have been a
reluctance to discharge patients to conditions unfavourable to complete
convalescence.

The Commissioners deal at considerable length in both reports with
the increased mortality which has occurred since 1915 among those
confined in county and borough asylums. In view of the disquieting
state of things revealed by the mortality returns, they very wisely
appointed three of their number to make special inquiry into the cir¬
cumstances which had determined the appallingly increased death-rate.
These Commissioners made special visits to twenty-six institutions,
and their conclusions and recommendations were embodied in a
circular letter dated January 15th, 1919, headed, “ Increased Annual
Death-rate in Asylums,” which was forwarded to all medical superin¬
tendents and clerks to visiting committees. Most of our readers will be
familiar with the terms of this communication. It is too long to quote
in extenso. We reproduce here the table showing the comparison
between 1913 and the years 1915-17 (adding the figures for 1918)
regarding the mortality per 1,000 in respect of each principal cause of
death.

1913-

^s-

1916.

1917.

1918.

Tuberculosis

Senility

143

Pneumonia

Dysentery

2 ‘2

Enteric fever .

I’2

An important point brought out is that for each of the assigned
causes the male death-rate surpasses the female, and that the excess
of the total male death-rate is considerable, even if the deaths from
general paralysis in both sexes are excluded.

The Commissioners attribute this alarming state of affairs in part
but not wholly to the effect of war conditions, such as the reduced
supply and deterioration in quality of food, the impairment of nursing

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efficiency, the movement of patients from one asylum to another, the
lower physical condition and greater age of the admissions, and to some
degree of overcrowding.

Other causes, which are likely to remain after the war, were im¬
perfect segregation of sick and infectious patients, lack of personal
cleanliness, and wrong methods of dealing with foul linen.

The recommendations made to meet these conditions appear to us
to be in the main eminently sound and practical, and no doubt will
receive the earnest attention of medical superintendents and asylum
committees throughout the country. Some of the recommendations
are already in practice in many institutions. Regarding more open-air
life, a relatively small increase in staff would permit of many more open
doors and windows, without having to adopt the retrograde mechanical
means as suggested. A sanatorium for tubercular mental cases is very
necessary in every larger mental hospital, though it might be an advan¬
tage if mental hospitals within a reasonable area could make joint use
of a separate and specially designed institution for this purpose. To be
really serviceable the sanatorium or ward set apart for tuberculosis
should be considered, like infectious accommodation and padded rooms,
as additional to the ordinary accommodation available for new admis¬
sions. The ideal plan the Board recommends regarding the attachment
to each institution of a special hospital under general hospital-trained
nurses, for the treatment of tuberculosis, dysentery, infectious diseases,
and illness generally demands careful consideration. The present mental
hospital infirmary seems to be very adequate for dealing with ordinary
medical and surgical cases. No doubt it would be an advantage to
employ hospital-trained nurses for supervision in the infirmaries and for
the training of the staff in sick nursing, for it is essential to mental
nursing that the ideals of the former should be reflected in the latter.

The great drawback to the mental hospital infirmary is the necessity
for treating there tuberculosis and dysentery. The present infectious
hospitals were meant no doubt to isolate odd cases of scarlet fever,
diphtheria, smallpox, etc., and have occasionally been useful for this
purpose, but they are too small to deal with an epidemic which assumes
any magnitude, while they are totally inadequate to deal with the
normal incidence tuberculosis and dysentery. The suggestion of light
temporary hospital buildings which from time to time could be taken
down, cleansed and rebuilt is, we think, an excellent one. Separate
buildings could accommodate tuberculosis, dysentery and infective
fevers, and when necessary be supplemented by tents. We see no
advantage, however, in including the ordinary illnesses in such an
arrangement.

A most important recommendation, for long advocated in the pages
of this Journal, is that regarding adequate facilities for bacteriological
and pathological work.

Adverting for a moment to the question of the responsibility of
war diet for the undue mortality, this subject was one of the bones
of contention between Sir Robert Armstrong-Jones and the eminently
practical superintendent of Bexley Mental Hospital in certain corre¬
spondence to the Times during September, 1919. The former pleaded
for greater regard being had to vitamines and less to calories in the diet

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provided for insane patients, while the latter could not agree that war
diet at all materially gave rise to the marked increase of mortality
reported in the Board’s report. Dr. Stansfield pointed out that in
his asylum the increase of mortality affected the men and not the
women while the quality of diet was the same for both. It seems
possible that the lower standard of efficiency of male nursing may
account in some measure for this owing to the greater depletion of
male nurses.

We fail to find anything in the Board’s report which “would emphasise
the necessity for a complete revision of the present treatment" of the insane
asstated by Sir Robert Armstrong-Jones, and hesubmitsnoextracts to justify
this sweeping statement, however true it might be. We venture to suggest
that it is well to be accurate, especially when the carefully worded ex¬
pressions of an important public authority like the Board of Control are
involved. In reality his letter only touches the Board’s report as far as
it deals with a specific subject, in this case the recent increase of mor¬
tality among the insane confined to county and borough asylums. Other¬
wise the distinguished late superintendent of Claybury Mental Hospital is
both inspiring and illuminating, and there is no question in our opinion
that the dieting of the insane is a matter of the greatest importance in
their treatment. The primary importance of vitamines is unquestioned,
nor should the question of calories be neglected. But mankind cannot
live on vitamines or calories, alone or both combined, if due regard is not
paid to the appetite, cookery, digestibility, personal diathesis, etc. Mass¬
feeding and ad hoc drastic weekly purging has no regard for the well-
recognised tendency to neuro-vascular abdominal disturbances and colitic
affections in those suffering from mental diseases and the neuroses. This
is one of the matters regarding which we think the Board’s control should
be strengthened, and their attitude something more than that exampled
in the reports of the Commissioners at the conclusion of their annual
visits of inspection, usually to the effect that they saw and perhaps tasted
so-and so served in the dining-hall or wards. It is a subject worthy of
careful investigation and experiment, and economic factors such as
cost, or the farm account, though important, are secondary matters.

Early in 1917, the Board laid before the Reconstruction Committee
an account of its duties in relation to lunatics and mental defectives,
together with suggestions for the amendment, in certain directions, of
the present Lunacy and Mental Deficiency Acts. In the following year
the Commissioners took a still more definite step by framing a Bill
embodying their suggestions regarding better provision for the treat¬
ment of insanity in its early stages, the establishment of in- and out¬
patient clinics at general hospitals, the extension of the principle of
voluntary boarders, etc.—matters which also have received the earnest
attention of the Association, various local lunacy authorities, and others
interested in better provision for the insane and the treatment of the
neuroses and diseases of the mind. It is unlikely, however, that much
advance will be made until Parliament has unburdened itself of some
of the colossal tasks it is at present engaged upon !

A matter of importance which has received attention from the Com¬
missioners is the effort of the nursing staff and other employees of
asylum authorities to secure better remuneration and conditions of

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service. We trust that the good offices of the Commissioners will be
chiefly in the direction of securing greater uniformity in the methods
adopted by the various local authorities in dealing with staff matters.
Some authorities are very active, others very sluggish—a uniform pro¬
gress would tend more readily to contentment than sporadic action.

In the report for 1917 will be found a rtsumi of the steps taken by
the Board which culminated in the creation of a new category of patients
known as “ service patients,” and a copy of the Board’s “ Instructions
Relating to the Classification and Treatment of Soldiers and Sailors as
Service Patients,” issued on June 27th, 1917, is included. The Com¬
missioners are to be congratulated on the success attained in their
prolonged and difficult negotiations with the various public authorities
concerned, and their adherence to the principle that sentiment when
necessary must make way for utility.

The average weekly cost of maintenance in public asylums, excluding
cost of repairs, additions and alterations, as might be expected, rose
considerably during 1917 and 1918.

1913-14. 1914-15. 1915-16. 1916-17. 1917-18.

105. <^\d. 1 ij. 1 \d. 115. 7 }d. 125 . 8§d. 145. Sjd.

Regarding cost, the public must be prepared to pay heavily for the
lunacy service for some years to come. It should be borne in mind,
however, that ultimately improved methods of treating insanity,
especially in its early stages, the outcome of special medical education
and improved status and better working conditions for the staff, will
save the public purse by lessening the accumulation of the chronic
insane, while there will be a great reduction in many branches of
public expenditure when the mentally deficient are segregated and
placed in surroundings where they are more likely to assist materially
in their own maintenance. It should be remembered, too, that mental
deficiency is a prolific breeding-ground of the chronic forms of insanity.

We are always pleased when public attention is drawn to prominent
examples of brave conduct among the nursing staff, and the deed per¬
formed by charge-attendant Bunner at Salop Asylum receives high com¬
mendation from the Commissioners. This occurrence is an illustration
of the self-sacrificing spirit of asylum nurses in their relationship to
patients, which all of us will bear witness to, and which is only too
readily forgotten by the occasional enterprising journalist who has
succumbed to the wiles and plausibility of the half-cured lunatic or
quasi-paranoiac or the really vicious defective with a bone to pick.

In the report for 1917, the Commissioners again refer to the question
of how best to prevent patients from injuring themselves with suicidal
intent. Of the twelve cases reported in 1917 and the seven in 1918, five
were known to be suicidal and presumably on parchment, and fourteen
were not known to be suicidal. Among the latter were several working
patients and one convalescent. The five who were known to be
suicidal evaded observation; the remainder found means, in some
cases of a remarkable kind, to gratify their wish. It would be
interesting to know the total annual number on parchment and the
number of these who made definite suicidal attempts. By such an
inquiry it would be possible to arrive at some idea as to how far it

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is possible to ascertain the presence of suicidal characteristics. Of
course it is commonly taught that cases with mental depression and
the so-called prompting hallucinations are the most suicidal, but
such teaching receives but little support from the Board’s annual
returns. Most of us will agree that all we can do at the moment is
to remove objects and means suggesting or permitting of self-injury,
and to keep up the respect for the suicidal parchment by only using
it in cases known to be actively suicidal. We are of the opinion that
more trained nursing staff and greater facilities for individual care are
the only real remedies, and if the country desires to be relieved to
any considerable extent of the shock of these occurrences it must be
prepared to foot the bill. On the whole, it should be well satisfied
with the results obtained.

Our review is already of undue length, but by no means exhausts
the points of interest and importance dealt with in these two reports.
Space will not allow of more than a mere mention of the mental
deficiency work of the Commissioners, which is steadily increasing in
dimensions. Time alone will show whether ultimately it will over¬
shadow lunacy, but there is no doubt that activity in this direction
will lessen lunacy operations, especially as regards the chronic insane.
The time may come when lunacy under a more appropriate name will
be largely a routine hospital matter like other diseases, the residuum
insane being housed in suitable homes, and with the degenerate, mental
deficient and criminal ceasing administratively to be primarily of
medical concern, though ever the subject of psychological medicine.
It is of interest to note that as regards the administration of the
Mental Deficiency Act, during 1918 there was some slight relaxation
of financial restrictions, and that the total number of all defectives
registered had grown from 7,941 in 1917 to 8,686 in 1918.

Thus in many directions does the Board show a virility which would
surprise a former generation of Commissioners. Though always posess-
ing a high sense of its duties and responsibilities, only of late
years has it appreciated the necessity of leading rather than following
all movements having for their objects the better treatment and care
of the insane and the advancement of psychiatry in general. The
need of a strong central lunacy authority keenly alive to the spirit
and needs of the times has been strongly felt in the past, and the
Board’s bold policy and outspoken utterances of recent years have
inspired a feeling of confidence and stimulated a desire for co-operation
with them, and have been productive of a unity of effort which is a
happy augury for successful achievements in the future.

The Brain in Health, and Disease. By Joseph Shaw Bolton, M.D.,
F.R.C.P. London: Edward Arnold, 1914. Pp. 479, with 99
Illustrations. Price i8j. net.

The keynote of this very useful book is provided by the author’s
generalisation of “ amentia and dementia.’’ We do not find in it any
appreciable alteration of his views as previously put forth in miscellaneous
papers, and though it contains some new matter, it is essentially a

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representation, in book form, of the essence of his previous writings,
so arranged as to,provide a comprehensive survey, from his special
standpoint, of the whole field of mental disease in relation to the
anatomy and pathology of the cerebral cortex.

For purposes of review it is convenient to consider first the above-
mentioned generalisation. Dr. Bolton, as is well known, uses the term
ametitia “ to connote in the widest sense the mental condition of
patients suffering from deficient neuronic development.” Under this
head he groups cases, not only of idiocy and imbecility, but of many
types of mental disease—“ chronic mania,” “ chronic melancholia,”
recurrent insanity, true epileptic insanity, some cases of hysteria and
certain cases of insanity with systematised delusions (developmental
paranoia)—all of which, he says, agree, from the aspect of morbid
anatomy, in possessing a subnormal average brain-weight, with normal
cerebral membranes, vessels and intracranial fluid, and, from the aspect
of histology, in possessing a subnormal development of the cortex
cerebri which, except in the severer grades, is limited to the pyra¬
midal or outer cell-lamina of the cortex. Cases exhibiting milder
degrees of amentia (“ high-grade amentia ”) form the connecting link
between the mildest type of imbecile or mental defective on the one
hand and the ordinary “sane” individual of average intelligence and
mental stability on the other.

The term dementia is employed “ to connote in the widest sense the
mental condition of patients who suffer from a permanent psychic
disability due to neuronic degeneration following insufficient durability.”
Under it are included all cases which agree, from the psychic aspect, in
the possession of a decreased or decreasing mental capacity, and, from
the physical, in the existence of a distinct and permanent loss of cortical
substance in those regions of the cerebrum which especially serve as a
physical basis for the carrying on of (voluntary) psychic processes.
Many cases are examples of natural involution of the cortical neurons,
occurring at periods determined by inherent resistance to decay; but in
many others the time at which dissolution commences, and the extent
to which it proceeds, are largely influenced by extraneous factors—
environmental, toxic or nutritional. If the process of neuronic dissolu¬
tion be one of normal involution, or be excited by permanently existing
and progressive factors (e.g., degeneration of cerebral vessels), it
continues more or less slowly until death; if, however, it be excited by
non-progressive, temporary or removable causes (e.g, alcoholic excess,
puerperal toxaemia), cessation of the cause may permit an arrest of the
process, and the patient may live for years in a stationary condition of
mental enfeeblement. Cases of dementia exhibit naked-eye post¬
mortem morbid appearances which vary in severity according to the
degree of dementia present. From the naked-eye point of view this
statement is said to hold good in a general sense, even when the progress
of the mental enfeeblement has been very rapid, and when, therefore,
the removal of the products of the neuronic degeneration is incomplete.

“ I hope,” says Dr. Bolton, “ that recognition of the fact that mental
disease consists in essence of a large group of cases with varying degrees
and types of cerebral degeneracy, and of another larger group with
varying degrees and types of cerebral dissolution, will be of value.”

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Such, then, is his generalisation of “amentia and dementia.” It is
very sweeping. With it he endeavours to cover the whole field of
mental disease; he does not indicate any territory over which his
generalisation prefers no claim. Of course, like everybody else, he
labours under some disadvantage from the fact that we possess no
adequate definition of “ mental disease.” And it is evident that the
terms “deficient development” and “insufficient durability” are purely
relative, their standards and criteria varying from age to age and from
place to place. To some readers, moreover, his view of mental disease
as “the greatest of the degeneracies” may appear pernicious, as
seeming to shut the door against other modes of investigation (e.g.,
those relating to the microbiology, endocrinology and psychogenesis of
mental disorders), and as consequently seeming to discourage thera¬
peutic effort.

Such objections, however, will not be deemed weighty by anyone who
appreciates the limitations to which all such working hypotheses are
necessarily subject. The acceptance of one such hypothesis does
not involve the rejection of every other. This of Dr. Bolton’s, for
instance, did not prevent him from consistently maintaining, for years
before the discoveries of Wassermann and Noguchi, the necessary
participation of syphilis in the aetiology of general paralysis. If, as an
objection to his generalisation, it could justly be urged that it is
obstructive to other lines of inquiry, analogous objections could be
made to the hypotheses underlying all of these also. To any who
should tell us, for example, that our only hope is in a recognition of the
psycho-genesis of mental disorders, it could be retorted, with equal
justice or injustice, that their cases have no brains, no bodies, no death,
no anatomy and no pathology, and that an exclusive adoption of their
standpoint would lead to neglect of the claims of the chronic insane
and of the physical needs of all men. There is, of course, ample room
for all the hypotheses indicated above, and for more besides. Each
must be judged by its positive results within its own sphere.

What are the positive results of Dr. Bolton’s hypothesis, as it is
expressed in his generalisation of amentia and dementia? That it
makes it possible to reduce the subject of mental alienation into a
coherent system is but the least of its results. That it led Dr. Bolton
directly to his valuable observations on the cortical cell-laminse is more
important. But most important is the continual incentive it gives to
the general study of correlation between clinical facts and anatomical
facts. This study is of two kinds; for, besides the special research,
conducted by technical methods often tedious and difficult, possible
only to the few, there is the study that should be continually pursued by
every asylum medical officer in the course of his ordinary work in the
wards and in the post mortem room—study depending mainly on naked-
eye observation, and not necessarily involving any methods that would
ordinarily be called technical or any extraordinary additional expendi¬
ture of time. Such study may seem to lack high ideal, but under
suitable impetus it can be widely diffused, and it is important because,
so far as it goes, it is on solid ground, and it continually leads on to
more vigorous applications of the method that has been employed with
success in the past in all the major investigations in the field of medicine.

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When once a medical officer has become acquainted with the gist of
Dr. Bolton’s teaching he acquires a new interest in the ordinary work of
post-mortem, examination, and he never loses it. At the same time he
is stimulated to refine his clinical examination of his patients, in order,
for example, to give greater precision to his conceptions of the clinical
aspect of that “dementia” with whose pathological anatomy he is
familiarising himself. Thus he is led also to a surer prognosis. Even
the weaker points in Dr. Bolton’s generalisation have use, as finger-posts
to new inquiry. Such is the value of a good working hypothesis.

To turn now to a closer examination of this volume—it should be
said that it contains little reference to the work of others, and is
devoted almost entirely to the author’s own observations. This being
so, its contents might perhaps have been arranged more effectively
if they had been made to follow mainly the historical order of
development of his thought instead of the more formal order of exposi¬
tion chosen. Having, in his opening chapters, dealt with cortical
structure and function in the normal brain, largely on the lines of his
Goulstonian Lectures of 1910, i.e., in the light of his micrometric
measurements of the cell-laminae, he proceeds to consider in a similar
light the cortex in mental disease, with the remark that “the data
contained in this chapter provide the main proof of the generalisation
of amentia and dementia.” The reader is rather apt to imagine, from
this, that the generalisation stands or falls by those measurements; and,
as that very arduous research was necessarily limited to a small series
of cases, he may well doubt whether such a small amount of material
can support such a large and weighty superstructure. The truth is that
the generalisation rests on a much broader foundation, already in great
part laid before ever that research was commenced; and nobody
contributed more to the laying of it than did Dr. Bolton himself in
Part I (pp. 426-545) of his paper in the Claybury Archives of Neurology ,
vol. ii, 1903, where he reported his preliminary investigations. There
he showed, by a comparison of the mental conditions with the naked-
eye morbid appearances in a series of 200 consecutive cases of insanity,
that a definite relationship exists between these. The germ of his
generalisation is discoverable even farther back still, in his Royal
Society paper on the visual area (Phil. Trans., 1900). For a due
appreciation of his work it is necessary to bear in mind these facts in
its history. In the present volume he might well have given references
to those papers.

It is not till later in the book that he deals with the naked-eye
observations which really lie at the root of the matter. Micrometric
work itself is but a more searching continuation of the naked-eye work
without which it cannot even begin. Thus the foundations of Dr.
Bolton’s teaching are of such a kind that any medical officer of a large
asylum has opportunity of testing them for himself in the course of his
ordinary work. The beautifully illustrated chapter on abnormal and
morbid naked-eye appearances is the work of a master, and is of the
highest general utility. It is perhaps somewhat regrettable, however,
that so little space is given to the difficult subject of convolutional
pattern in relation to amentia. In this connection reference is made to
the influence of mechanical conditions of growth; any extended

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account of this being precluded by considerations of space, a few
suggestive instances might have helped to remove the vagueness and to
put the reader in the way of finding others.

The last and largest portion of the book sets forth at length the
clinical aspects of the amentia and dementia thus anatomically defined,
and the various intra-vitam data for their recognition. Here the
author surveys practically the whole field of mental diseases, following
for the most part the lines laid down in his papers on “ Amentia and
Dementia” published in this Journal in the years 1905-1908. Notes
are given of many illustrative cases. Attention is chiefly devoted to
those groups of cases in which the applicability of the generalisation is
least obvious. Thus, under “amentia,” idiocy and imbecility are but
briefly mentioned, but “high-grade amentia” is discussed at length.
Under “ dementia ” evidence of various kinds is produced to show that
general paralysis, though syphilitic infection is a necessary antecedent to
its occurrence, is not a special organic disease of the cerebrum— i.e., it
is not a mere syphilis of the brain, but is a branch of ordinary mental
disease within the scope of the generalisation, and, were syphilis non¬
existent, the majority of existing cases of general paralysis would merely
be replaced by cases of primarily neuronic dementia.

Junior students should notice what a large proportion of Dr. Bolton’s
illustrative cases are chronic cases, and how instructive these become
when regarded from his standpoint. In this we have but one instance
among many showing that his teaching, being rooted in asylum
experience, is peculiarly adapted to the asylum physician’s practical
needs. Both in subject-matter and in method the work here presented
by the Leeds professor is thoroughly indigenous to the asylum soil. To
many British psychiatrists we are indebted for valuable results of special
research; to some, for the excellent text-books they have given us; to
Dr. Bolton we owe thanks for presenting to us in this book the essence
of those original papers by which, during the last eighteen years, he,
more than anyone else, has given impetus to our asylum work in
general, through the inspiration of an eminently serviceable and truly
native hypothesis. Sydney J. Cole.

May, 1920.

Diseases of the Nervous System: A Text-Book of Neurologv and
Psychiatry. By Smith Ely Jelliffe, M.D., Ph.D., and William
A. White, M.D. Philadelphia and New York: Lea & Febiger,
1919. Third edition. Medium 8vo. Pp. 1018. Illustrations,
470 engravings and 12 plates. Price §7.

Many of our readers will be familiar with the previous editions of
this combined text-book of neurology and psychiatry. The third
edition, revised, rewritten and enlarged is a substantial volume of over
1,000 pages, profusely illustrated, a work designed to suit the con¬
venience of students and practitioners, and which includes the new data
which have accumulated during the war in the domains of both these
sciences.

The union of these allied subjects in one treatise has its advantages,
for the practice of either constantly involves a knowledge of the other,

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though the difference between them almost equals that between medicine
and surgery. Neurology, like surgery, is almost an exact science; and
although evolving on similar lines, it will be many years before the same
can be said of psychiatry and medicine. Similarly the surgeon and the
physician and equally the neurologist and psychiatrist differ in mental
build, and thus it happens that it is rare for a neurologist to have a real
insight into normal psychology or the working of the diseased mind.

The authors, however, of this text-book have constantly in mind
three levels of treatment of the subject—the vegetative, the sensori-motor
and the symbolic being different aspects of the mental and physical
problems “as expressed by the various forms of solutions and com¬
promises made in the process of integration and adjustment. Not only
are the different levels not distinct, but the same symptom may
arise as a result of disturbance at any one of the levels. For example,
constipation may be due to a disturbance at the vegetative level
(vagotonic spastic constipation), at the sensori motor level due to injury
or disease of the cord, or at the symbolic level—a purely psychogenic
symptom.”

It will be admitted that it is very necessary for every alienist to have
a good practical knowledge of neurology, and this can be found in the
work before us in a useful and readily assimilated form.

In pursuance of their plan, the authors divide their book into three
parts: Part I—“The Physico-chemical Systems or the Neurology of
Metabolism”; Part II—“The Sensori-motor Systems or Sensori-motor
Neurology”; Part III—“The Psychical or Symbolic Systems or the
Neuroses, Psychoneuroses and Psychoses.” Prior to these is a chapter
devoted to clinical methods of examining nervous and mental cases,
rich in details, and including many anatomical data, schedules of
“questionnaire” and psycho-analytic procedures. As regards Part III
we cannot but feel some disappointment, for, as in previous editions, it
is very considerably a reproduction of the familiar teachings of Freud,
Kraepelin and others of the Germanic school, with a minimum of
mention of the work of other schools. As expositors of the German
school of psychiatry our authors are excellent and their presentation of
it eminently clear and readable. In this sense Part III will appeal
mainly to a not uninfluential section of British psychiatrists, which,
however, cannot lay claim at all to include the majority.

It might be urged that only the German teaching will fit in with the
fundamental tenets upon which the work is founded, but this is not
really so, for there is much more in common between the British
and German schools of psychiatry than would appear on the surface,
and even in many respects the former can claim priority, especially as
regards basic facts. This is a fascinating aspect of the subject we
cannot develop here, but speaking generally w’e would have been more
pleased had our authors had more resource to the rich store-house of
their native psychiatry for inspiration and knowledge.

The introduction to the psychical section states that “ Present-day
psychiatry is almost wholly a product of this century. Nineteenth
century psychiatry, even well along in its latter half, had only a few
relatively simple concepts with which to approach the problems of
mental disease ”—a strange historical retrospect, inconceivable to those

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even moderately versed in the literature and work of the nineteenth
century—an unparalleled period of psychiatrical renaissance.

As our readers are well acquainted with the works of Freud and
Kraepelin little need to be said here regarding the chapters on
the neuroses, psychoneuroses and psychoses. Neurasthenia is con¬
sidered “ as the expression of a very marked auto-erotic fixation ”—in
other words due to excessive masturbation, frequent pollutions or
auto-erotic fantasies. Freud supersedes Janet in the mechanism of
hysteria, and psychasthenia is replaced by the compulsion neuroses.
“Shell-shock” has a brief paragraph devoted to it and is divided into
cases with actual physical nervous injury and cases of true conversion
hysteria, or anxiety hysteria. This is also Mott’s view. Anxiety
neurosis is the outcome of inadequate discharge of the energy of the
sexual act in the psychic sphere. As regards the actual psychoses,
manic-depressive insanity remains in its usual setting, but involutional
melancholia has ceased to be a stumbling-block, and has joined the manic-
depressive group. Epilepsy is treated from a distinctly wider standpoint,
and dementia praecox historically is fairly stated. The symptomatology
of the latter is given on the usual lines, and its nature and pathology
discussed at length. Our authors conclude that for the present it must
be considered as an introversion psychosis and the explanation of its
symptoms sought psychogenetically. Having regard to Mott’s recent
work on this subject and his conclusion that dementia praecox is a
primary nuclear degenerative process with no inflammatory reaction,
and also its relation to the endocrinopathies, it seems possible that, like
general paralaysis, it will eventually be removed from this section of the
book. The psychogenetic schools, especially those with a strong sexual
bias, are slowly but surely being undermined in the interpretation of the
true psychoses by the work of Mott, Robertson and Shaw Bolton and
others. The question of cause and effect in relationship with pathology
and psychopathology is of vital interest to alienists, and no school can
afford to be dogmatic in this matter in the present disturbed state of
our knowledge. The endocrinologist, the bacteriologist and the bio¬
chemist, as yet shadowy figures, are slowly materialising, and their
day is yet to come when many a cherished theory will fade away and
become a curiosity to future generations.

Parts I and II, which form the bulk of the work, can be whole¬
heartedly commended. An immense field of neurology is covered, the
whole being work characterised by a clarity of diction, unclouded
reasoning, a comprehensive marshalling of masses of details, and quick
and convincing decisions. The endocrinopathies form an absorbing
chapter full of interest to the alienist, the mental desiderata being very
ably written. Ophthalmic migraine is exhaustively dealt with, and
among the sensori-motor disturbances the sections dealing with speech
disturbances, aphasia and neuro-syphilis merit special mention.

The scheme of kinetic speech disturbances adopted is one by Vera-
guth, and the description of the aphasias is not overburdened with a
number of confusing and, after all, not very important more or less
theoretical subvarieties. “To completely analyse a single case of
aphasia according to present-day requirements requires years of pains¬
taking observation, two or three years of more or less continuous
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microscopic technical manipulations, and at the cost of thousands of
dollars.” Would that all writers of text-books developed such candour!

General paralysis is placed in the neurological section in the chapter
on neurosyphilis. It is called the parenchymatous or central type of
cerebral syphilis and described in six forms: dementing, depressed,
expansive, agitated, irregular and juvenile. The view is taken that the
pathological processes are all the same in neurosyphilis, and “the
clinical manifestations extremely variable, complex and confusing,
depending upon the interactions of the pathological trends and the
localisation of the anatomical paths interfered with.” Commenting on
the pessimistic atitude adopted to general paralysis, it is remarked that
“ this is one of the gravest reflections brought against a laissez-faire
handling of the so-called ‘hopeless paretic’ in institutional or in
private work. Many curable paretics are grossly neglected because
they are diagnosed incurable. Neurosyphilis meningovascularis is
usually very amenable to treatment. Often its clinical picture is that
of a paretic.” A case illustrative of this recently occurred at Brentwood
which was investigated by Mott and Turner. The relationship between
the Argyll-Robertson pupil and cerebral syphilis, its variability and
significance during treatment is discussed at length. Its presence
is considered a fairly positive but not absolutely positive proof of
nervous syphilis. Its absence, however, by no means negatives
syphilis of the nervous system. This chapter is one of the best in the
book and nothing more comprehensive will be found anywhere.

Though there are now many really fine modern English text-books of
psychiatry to select from, yet none of them cover quite the same ground
as the one under review, which is especially valuable for its correlation
of neurology and psychiatry, and a useful volume to have at hand as a
work of reference for both students and practitioners, especially
those with a meagre medico-psychological library and few facilities for
consulting the larger standard works. J. R. Lord.

A Manual of Neurasthenia (Nervous Exhaustion). By Ivo Geikie
Cobb, M.D., M.R.C.S. London: Bailliere, Tindall & Cox.
Demy 8vo, pp. xvi + 366. Price 125. 6 d.

This is a book which will appeal to general practitioners who of late
have been striving to retain a practical and common-sense attitude
towards a subject they have to deal with constantly in their daily round
of work. Of late there has been a flood of literature on the neuroses
and psycho-neuroses, much of it difficult for the busy man to follow;
facts claimed to have been established which apparently are entirely
against cherished convictions and experience; and lines of treatment
advocated which seem impracticable except in the hands of the
psychiatrical expert. A judicial work which endeavours to correlate
all that is known on a much-discussed subject, having regard to practical
applicability, is always welcome at such a juncture, and this Dr. Cobb
endeavours to supply.

Whatever is the real meaning of the conditions which are covered
by the term “ neurasthenia,” to the physician it is a definite malady

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presenting variegated yet constant features. The condition dealt with
in this work is neurasthenia in a wide sense, the author’s definition
being “ a condition of nervous exhaustion, characterised by undue
fatigue on slight exertion, both physical and mental, with which are
associated symptoms of abnormal functioning, mainly referable to
disorders of the vegetative nervous system. The chief symptoms are
headache, gastro-intestinal disturbance and subjective sensations of all
kinds.”

The historical section traces the career of neurasthenia from the
original description by Beard, of New York, in 1868, noting that
as far back as 1843 E. Hersch described the nature of neurasthenia
“in a way which corresponds entirely with our modern views,”
through the onslaught of the psychopathic school, describing the
influence of Clifford Allbutt, Tanzi, Mott, and Stoddart as regards
its definition and aetiology, down to the author’s own conception of
the disease.

Chapter II deals with aetiology from the standpoint of sex, age, class,
heredity and physical agents, laying great stress on influenza, which
“ may be regarded as an extremely frequent and potent source of
neurasthenia.” The mental aspects, mental causes and effects are dealt
with in a separate chapter. The close interaction between psychical
and physical causes is insisted upon. Neurasthenia is a psycho-physical
disorder in which the influence of heredity and the degree of normal
stability must not be under-estimated. The psychological schools led
by Prof. Freud are agreed with in part, and due note is taken of the
influence of mental dissociation, upon which great stress is laid by the
American school. Dr. Cobb’s telling manner of dealing with the many
divergent views carries with it the conviction that the truth of the
matter lies in a middle course. The schorl which lays it down that
neurasthenia is the outcome of masturbation assisted by mental fatigue,
toxaemias, etc., is too narrow to meet the results of practical experience,
even excluding such conditions as anxiety neurosis, with which there
need be no confusion.

Several chapters deal with symptomatology, asthenia, headache,
gastro-intestinal symptoms, sensory disturbances, insomnia and objective
signs. All are fully described with praiseworthy clarity, especially the
gastro-intestinal disturbances. For example, the latter embrace anorexia,
catarrhal disorders, disorders of secretion, dilatation and ptosis, and con¬
stipation—intestinal and rectal. As regards these, the vexed question
of cause and effect is discussed at length. Nervous symptoms may
precede or follow their appearance—in any case, once established they
have a profound effect on the neurasthenical condition, and it is
imperative that they should be treated carefully. Truly many sufferers
by the time they seek advice are a “ tangled skein,” and it is important to
study every morbid symptom presented and call in every assistance to
reach a correct diagnosis of the many affections that may arise.

In the chapter on diagnosis a claim is well sustained for neurasthenia
to be considered as a separate clinical disorder. The author does
not include phobias, obsessions, anxiety states, etc., and his defini¬
tion of neurasthenia is in reality only a part of Beard’s original
conception of the disease.

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A good fourth of the book is devoted to treatment under such
headings as general hygiene, diet, drugs, climate, psychotherapy,
electricity and special treatments. All of this reads sound, nothing
impracticable is suggested, and the details of treatment are easily
followed and inspire confidence. Psycho-analysis is recognised as being
useful in selected cases only, the majority needing other therapeutic
procedures.

The range of this work will now be manifest to our readers, and its
advent at this moment will satisfy a real want in view of the present
disturbed state of our knowledge on this and allied subjects.

J. R. Lord.

Shell-shock and its Lessons. By G. Elliot Smith, M.A., M.D.,
F.R.C.P., F.R.S., and T. H. Pear, M.A., B.Sc. New Impression,
Manchester: University Press. London: Longmans, Green & Co.,
1919. Pp. 135. Cheap Edition, is. 6 d.

This excellent little volume was first published in 1917 and a cheap
reprint is to be welcomed, as it may thereby gain a larger circulation
among the general public, for whom it is intended, as well as for members
of the medical profession. Though the war is over the question of the war
neuroses is still a pressing one both from a social as well as from an
individual point of view. There is no doubt that a number of these
cases are drifting into a condition of chronic inadequacy on account of
their nervous illness, and it is of great importance that the practitioner
should know how to deal with them, and thus be in a position to direct
them towards a life of happiness and utility. The nature of “ shell-shock"
and its treatment are explained in clear and non-technical language, the
psychogenetic factors are emphasised, and stress laid on the importance
of psychological analysis and re-education in bringing them back to
mental health. Sufficient is said to indicate the extreme interest of the
subject, and no one could read the book without realising the utter
inadequacy of mere “ tonic treatment ” for any form of psycho-neurosis—
a form of treatment which is even now often the only therapeutic agent
employed. The authors state in the introduction that their aim in this
volume extends beyond that of the problem of the war neuroses, and
they express the hope that the lessons of the war in respect to the
treatment of mental disorder will be followed by a more enlightened
policy in the case of civil psychoses and neuroses. The statement that
“To the long list of sciences which . . . must be cultivated more

assiduously after the war should be added—but not at, or even near, the
end—psychiatry, the science of the treatment of mental disorders,” will
find general assent from those concerned with this particular branch
of medicine. The concluding sections of the book deal with the defects
in the present system of treatment and the directions in which reforms
should be undertaken. These matters are, of course, quite familiar to
readers of this Journal, but such views can hardly be too widely diffused
amongst the profession generally and the educated lay public.

We may perhaps suggest, however, that the layman,after reading this
book, will probably gain a much more unfavourable view of asylums

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than they deserve. The defects, largely the result of the system under
which they have to be administered, receive every emphasis, but the
advance in the care and treatment of the insane in these hospitals,
which is so remarkable in many directions, is entirely overlooked.

H. Devine.

Etude critique sur PEvolution des Idles relative a la Nature des Hallu¬
cination Vraies. By Dr. Raoul Mourgue. Paris : Jouve et Cie,
1919. Pp. 67.

It may almost be said that no problem of psychiatry is more deserving
of attention than that of hallucinations, in so far as it inevitably includes
the elucidation of other associated abnormal mental symptoms, such as
the feeling of being controlled and influenced, and the delusional
rationalisations which the individual erects in order to explain his
unaccustomed mental experiences. As the title indicates, this study
does not aim at suggesting a new theory, but it includes a review of the
various conceptions, especially those of the French school, as to the
nature of hallucinations. It is thus a useful little book of reference for
those interested in the subject, especially as it includes an excellent
bibliography.

In his introduction the author suggests that in psychiatry the time
for wide generalisations has passed, and that what is now required is a
return to the analytic study of facts. He points out how the Kraepelin
school, with its emphasis upon nosographic, aetiological and prognostic
considerations, and its neglect of isolated symptoms has been in a certain
sense harmful to the study of hallucinations, and especially so to the
psychological conceptions which are essential to the understanding of
the subject. He proceeds to trace the development of the various
theories, including the earlier ones in the seventeenth century, which
have been advanced to account for hallucinatory phenonema, and after a
survey of the current anatomical, clinical, and intellectual theories he
inclines to the view of Baillarger in 1846, who ‘among all the authors
studied has appreciated the difficulty of the question, and who counselled,
with the prudence of genius, the patient and analytic study of facts,” and
for whom “ no theory was yet possible.”

On the whole the theories here discussed are somewhat mechanical,
and especially do we miss any reference to the important studies of
Flourney in regard to teleological hallucinations. The absence of any
discussion of the influence of the unconscious, and of the dynamic
factors instrumental in the production of hallucinatory phenomena
somewhat diminishes the value of this study. H. Devine.

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Part III.—Epitome of Current Literature.

i. Psychology and Psycho-Pathology.

Social Fatigues and Antipathy [Les Fatigues Sociales et PAntipathie\
{Rev. Phil., Jan.-Feb., 1919.) Janet , P.

In this article of 71 pages Prof. Janet deals with the question of the
influence which neuropathic subjects exert upon those with whom they
are associated. Each point in this paper is emphasised by reference to
actual cases, and it contains a wealth of clinical detail which cannot be
included in an epitome. To understand fully the therapeutic value of
isolation, and to apply it with precision, it is necessary to consider the
costly effort which life in society exacts, to consider the influence of one
man on another, especially in so far as one individual by his exactions
may create a state of lowered psychological tension in another with whom
he is associated. A study of the social conduct of a neuropath in
relation to his family will indicate how and why separation from certain
persons is so important in some instances. These psychasthenics
exhibit social abulia, avoidance of any effort, lack of practical achieve¬
ment ; they can neither command nor obey, they are incapable of real
affection, and though they talk much of their feelings, these result in no
kind of service for others. Not only do they protect themselves from
actions which they dread, but they hinder and oppose others in the
family and have the whole household at their mercy. There are a
number of morbid impulsions and inferior mental operations by means
of which the neuropath dominates the family. Thus there is the mania
Jor helping , in which the individual wishes to participate, and actually
hinders, the activities of others, an exaggeration of that tendency of those
incapable of physical exercise to watch sports or read sporting papers.
A patient expresses this attitude in the phrase, “ My dream is to sit with
a man who works, especially a man who writes. Oh! let me watch you
write for a whole evening.” This tendency may extend to an insistence
on useless and futile collaborations. Then there is the mania Jor
authority. Giving orders when it implies direction and initiative is a
difficult psychic operation, but there is an elementary form of domination
in which an individual formulates an action without accomplishing it
himself and without any consideration as to the value, utility or interest
of the act. Neuropaths find in such orders extreme satisfaction and at
times people placed in positions of authority develop a mania of this
kind. Neuropathic authoritatives are divided into two types, those who
seek to obtain obedience by moaning entreaties, and those who attack
and threaten the members of the family in order to reduce them to
slavery and to prevent them from having any freedom. Such patients
will obtain their desires by threatening to die if they are thwarted, or by
insisting on constant sympathy, any relaxation of such an attitude
provoking a scene. Obedience is also secured by the mania Jor love t
the constant demand for every expression of affection. Prof. Janet
points out that all these abulics are extremely insistent on their “ rights,”
whereas the man of action is not worried with his rights but devotes

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himself to the task in hand. Domination is sometimes secured by the
mania for devotion , in which individuals are constantly rendering little
services and giving useless presents to others, such generosity having
always something bizarre and abnormal, designed to humiliate and exact
innumerable thanks. It is only a method of acquiring recognition,
protection, regard, flatteries, of playing a rile.

Unfortunately all these efforts to dominate, to make themselves loved,
do not succeed and do not cure the patient, and so he adds new efforts,
which in their turn degenerate into forms of mania. Thus there is the
mania for teasing and sulking. The former depends on the need of
verifying their power over people; it is an attack, a wound, a humilia¬
tion made on someone it is desired to dominate, from whom caresses
and flattery are desired. Pouting and sulking have a similar mechanism
proceding by the method of indifference and simulated rupture. Both
these forms of conduct are often completed by the act characteristic of
a neuropath known as “ making a scene ”— mania for scenes. Other
pathological manifestations are morbid jealousy, the mania for disparage¬
ment, and the mania for spitefulness.

Such characteristics naturally provoke a reaction on the part of those
with whom these psychasthenics are associated, and this reaction is
essentially complicated and difficult. The relatives have to decide and
choose for them, keep their interests in the foreground, accept
responsibility for all their actions. They are essentially gloomy, they
prevent actions in others, and interfere in those which they permit.
The mania for orders involves obedience to all kinds of absurd
commands; the continual complaints tend to give rise to a similar
attitude amongst the entourage; the mania for rights inflicts constant
humiliations and provokes a reaction of defence; the mania for scenes,
as for instance in a jealous husband, necessitates that every action and
gesture must be guarded and almost the whole social life abandoned.
Such reactions are of necessity exhausting and only possible at
considerable expenditure of mental energy. Antipathy is generally
regarded as an intuitive dislike of people, a warning that there is
something dangerous about them, but the view is here developed that
antipathetic persons, those whom we fear and fly from, are those who
menace us with a real danger which psychologists have not understood ;
they menace us with weariness, with mental depression, exhaustion.
Individuals are economical of their mental activity, they feel a
commencing hatred of, a sentiment of aversion for, a desire to rid them¬
selves of those who exact an increased expenditure of mental energy and
who necessitate an increase of psychological tension.

The question of the neuropathic group and the contagion of the
neuroses is next considered. In any given social group an isolated
neuropath is the exception and around him are nearly always others
showing signs of some form or another of lowered psychological tension.
In families this is often regarded as evidence of heredity, but this is not
always the case—it is rather the result of the stress which one
neuropathic person exerts upon those with whom he is associated. The
social characteristics of psychasthenics are such as to create a condition
of lowered psychological tension in those with whom they are in contact
owing to the prolonged mental effort and complex reactions which their

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conduct demands on the part of their associates. This mechanism, to
which the term contagion has often been loosely applied, is responsible for
many cases of mental disorder. The writer points out that for the
public the term mental disorder is confined to definite insanity, the
milder forms not being recognised as such. Insanity is really only a
legal and not a medical term, and there exist to-day on all sides
individuals of the type described who are not regarded as suffering from
mental trouble or indeed any illness at all. Many of these cases and
also their families would be astonished if they were told that their
trying conduct was the expression of mental disorder. It is most
necessary to notice carefully the influence of a neuropath upon his
social milieu, especially from the point of view of treatment of the
dangerous member of a group by isolation, in order to arrest the
already threatening neurosis amongst the other members.

H. Devine.

The Symbol as an Energy Container. ( Journ. Nerv. and Ment.

Dis. } December , 1919.) Jelliffe, Smith Ely.

Life is dependent on the energy around it. Being marked by the
quality of growth, it must not only seize the energy through its proto¬
plasmic structure, there transform it, and then put it forth, but it must
unceasingly devise new means, new carriers for all these three processes.
Human speech is such a means. Not consciously but unconsciously,
man has made words because he has felt, though not understood, the
necessity for a larger and wider self-expression—for more capture of
energy, more work upon it within himself, and more giving of it out.

The psychic significance of language is to be sought in the symbolism
it represents. The history and development of desire, and its striving
through successive ages of culture, show how it continually overflows
any container or pathway by which it may be expressed ; so the symbol
must be that which comes to express, first, the simple direct chemico-
physical needs, then the more complex organic wants which have grown
out of these, and far more, in course of time, the social reactions. It
sweeps the gamut of human experience, from the lowest reactive
sensation up to the remotest re-symbolisations of intellectual thought
with its ever-present emotional accompaniment. This cannot all
become conscious; conscious awareness could not attend to all this at
once, as it might appear in one line of action. The various cultural
psychic layers constituting the individual mind are too numerous, and
are mostly too inacceptable to the cultural standard existing at the top.
Yet they cry for expression both as feeling and as idea.

In act, in decorative art, in religiou« custom, in sound, but most
elaborately and extensively in speech and language, the symbol has
been and still is being prepared for this service. It is the means
whereby the hidden desire, with its idea, is touched and its energy
secured, while it still covers and obscures the actual meaning of these
so that the higher cultural standard is satisfied and finds its own full
representation. The symbol becomes the great energy container and
the great comprehensive device of discharge back to the world outside.

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Language has a trend towards fixity, without which it would be
deficient in value. Yet to a large extent this fixity is only apparent.
For the word is the tool of a constantly fluctuating life; it is not only
the container of what has been, but the suggestive and plastic symbol
of what may be. Language is no static thing. In the mouth of the
last speaker it takes colour and force from his mental life: a definite
act of creation takes place (“ the chief and only really satisfying act of
life ”), and through it a contribution to evolution.

Every word, as a symbol, contains in its history “a monograph on
the cultural history of mankind ” (Mauthner); and psycho-analytic
literature has dealt abundantly with the actual unconscious content of
the symbol—that which gives it one side of its energic value. But
equal emphasis must be laid on its dynamic significance : as it is always
reaching out towards the environment of the present, and through the
present into the future, so it builds up the communal feeling (Glatz)*
and cradles and nurtures morality (Dacien). Sydney J. Cole.

Retro-active Hypermnesia and other Emotional Effects on Memory.

(Psych. Rev., November , 1919.) Stratton , M.

As effects of excitement may be noted— (a) those which are tran¬
sitory, occurring during the excitement, and (b) those which persist.
As transitory effects there may be an apparently general hypermnesia,
in which there is a marked freshening of all memories, or there may be
a selective hypermnesia, where certain rather narrow lines of association
are followed. The lasting effects may be hypermnesia, hypomnesia, or
total amnesia for events experienced during the excitement. The
following lasting effects may also be noted upon experiences that have
occurred before the emotion: (1) The well-known retro-active amnesia;
(2) The opposite, retro-active hypermnesia to which little attention has
formerly been paid ; (3) a combination of both these effects; for the
same person the stretch preceding the critical event may show vivid
recollections followed by a period of utter blank. The retro-active
hypermnesia in the author’s cases rarely goes beyond the events of the
day preceding the excitement. It occurred in 25 out of 225 cases.
The antecedent events are unusually vivid—more vivid than any other
of the patients’ memories. The vividness is not confined to visual
images, although these are more frequent; sounds, the mood, the
general state of the mind may be clearly represented. There is some
indication that women experience it more frequently than men. In
some cases the effect has come at some crisis at early childhood, in
others at a later date. The quality of the emotion seems of less
importance than the intensity of the shock. Fear, or fearless surprise,
or pleasurable surprise may be the cause. If the intensity be exceeded
the experiences connected with it are in some degree suppressed;
while if it be not reached the experiences are lost probably by a mere
failure to gather up the events into the mesh of interest. Emotion
facilitates the recall of whatever is noticed during the excitement, and
it seems probable that memory images may be treated by the emotional
onrush in the same way as perceptive images. The experiences of the
preceding day, however, probably do not exist as actual images at the

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time of the emotion but as psycho-physical dispositions or traces, so that
where there is retro-active hypermnesia the emotion would seem to
have the power to strengthen these dispositions and the connections
by which they may be called into life. The author gives illustrative
cases. C. W. Forsyth.

2. Neurology.

Some Observations on the Influence of Angle of Section on Measurements
of Cortex Depth and on the Cyto-architectonic Picture. ( Journ .
Nerv. and Ment. Dis., April, 1918.) Orton, S. T.

The author gives the results of his control measurements of sections
from various cortical areas. He used a special block-holder, equipped
with a scale, and rotatable, so that from one block of cortex seven or
eight planes of section could be made, cutting the cortex at as many
different angles. All the measurements were made at the apex of con¬
volutions, where the axes of the majority of nerve-cells pass vertically
into the white matter. The depth increments referable to obliquity are
tabulated as percentages of the shortest measurement. He concludes
that, using sections cut and mounted with extreme care to avoid undue
obliquity, one may expect an error of something under 6 per cent., of
which almost one half is due to difficulty in determining the line of
demarcation between cortex and white matter. The fixing of this line is
somewhat arbitrary, owing to the rather gradual and straggling manner
in which the spindle-cells of the lowest cortical layer disappear as the
white matter is reached.

The cyto-architectonic picture is not much altered except when
obliquity is marked. Owing to the wide variations in their vertical
orientation, the apparent shape of the pyramidal cells will not serve as
an accurate control, though, by ascertaining the proportion of trun¬
cated cells to those with long processes, one could probably detect an
obliquity sufficient to induce a depth error of 10 per cent.

He discusses the significance of depth for evaluation of the cortex,
and considers the spatial importance of the vascular system and
neuroglia, as well as of variations in the number and volume of nerve-
cells and nerve-fibres. He notes the occasional occurrence of great
cell richness in a thin cortex, due perhaps to lack of development (or
possibly to devastation) of intercellular structures, or to diminished
thickness of myelin sheaths. A small brain, whose size is dependent,
not on a reduction in number of essential structures, but rather on the
size of the constituent elements, may yet in a functional respect be
fairly normal. Sydney J. Cole.

3. Clinical Psychiatry.

Atypical Form of Arteriosclerotic Psychosis: A Report of a Case.
{Journ. Nerv. and Ment. Dis., December, 1919.) Uyematsu , S.

A married woman, set. 40, began to have difficulty in doing her
work, complaining of headaches, which gradually became more severe.
Her memory gradually failed for both recent and remote events. After

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1920.]

about seven years walking became difficult, and finally she was bed¬
ridden, being unable to stand. A tremor of the hands developed, and
it was necessary to feed, dress, and care for her. No syphilitic
evidences; Wassermann negative in blood and spinal fluid. No sclerosis
of peripheral arteries. Blood-pressure 160-80. Pupils irregular, the
right dilated; reaction to light slow, to accommodation nil. Tactile
appreciation slightly impaired; inability to localise readily for touch or
space; wincing to pin-pricks. Knee-jerks exaggerated. Right ankle
clonus. No Babinski. Marked tremor of hands, tongue and lips.
Speech retarded and slurring. The clinical condition much resembled
general paralysis, except for its protracted course and the negative
Wassermann. Diagnosis, “ cerebral tumour ? ” Died comatose at the
age of 48.

Brain 970 grm. Dura thick. Pia slightly opaque; much fluid beneath
it. Diffuse atrophy of convolutions, very marked over vertex, and
involving the posterior parts of the frontal lobes, and the entire parietal
and occipital lobes. The only parts that did not show this curious
atrophy were the orbital portions of the frontal lobes, anterior part of
superior frontal gyri, anterior part of gyrus fornicatus, the superior and
middle temporal gyri, opercular portion of left hemisphere, the insulae and
unci. The healthy portions are related to certain regions of arterial
blood-supply. At the points of greatest atrophy the cortical surface
had a moth-eaten appearance ( itat vermoulu of Pierre Marie). Old
haemorrhage in left internal capsule. The vertebral arteries, basilar,
internal carotids and major arteries of cerebrum and cerebellum all
very sclerotic. Sclerosis of coronaries ; commencing sclerosis of aorta.

In the cortex, immediately under the glial surface, were many small
cystic areas, mostly triangular or wedge-shaped, with their bases against
tbe surface. Some lay deeper, and these were mostly under the valley
between two gyri. The cysts were surrounded by a luxuriant growth
of glia. The inside of the cyst was not empty space, but was occupied
by a net-like structure of capillaries, perivascular connective tissue, glia
fibres and a few cellular elements. The condition is rare, and resembles
Fischer’s spongioser Rindenschwund. Side by side with cystic areas
were scar-tissue formations. The smaller vessels of the cortex showed
here and there a “ packet formation.” Somewhat similar changes were
found in the cerebellum. The author attributes them all to arterio¬
sclerosis, of unexplained aetiology, not syphilitic. No syphilitic
endarteritis found anywhere.

A full and detailed report. Fifteen photographs; those showing the
naked-eye distribution of the atrophy are particularly interesting.
Commentary; survey of literature ; bibliography.

Sydney J. Cole.

General Paralysis and Traumatism. [Paralysie GStiirale et Trau -
matisme\. ( Rev. Neur., No. 22, October, 1915.) Benon , R.

This prolific writer here surveys the diverse opinions of authors
respecting the significance of injury in the aetiology of general
paralysis, since the first description of the disease by Bayle in 1822,
and gives eighty-four references. He considers that injury can act
neither as a determining nor as a predisposing cause, and that it is very

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doubtful whether it can act even as an occasioning cause. Injury can, of
course, accelerate or aggravate a pre-existing general paralysis, but it is
not certain that it can give rise to the disease, even in a syphilitic
subject. On this point, scientifically, an attitude of the greatest reserve
is necessary, but for medico-legal purposes it is often right that an
injured person should have the benefit of the doubt. The writer sets
forth the differential diagnosis between traumatic dementia (strictly so-
called) and post-traumatic general paralysis. His account of the
medico-legal aspects of the question is mainly of French interest.

Sydney J. Cole.

The Diagnosis of “ War Psychoses .” (Arch, of Neur. and Psychiat.,
vol. 2, no. 2, August , 1919.) McPherson , G. E., andHohman , L. B.

The writers consider that many diagnostic mistakes were made in
war psychoses owing to the tendency to crowd cases into one of the
two great pigeon-holes, manic-depressive insanity or dementia praecox,
and that in many instances little attempt was made to understand the
cases as reactions in terms of personality, conflicts and wishes. Many
cases showing symptoms of these psychoses occurred in unadaptable
individuals and the disorder readily cleared up upon removal to
hospital. Many illustrative cases are given which enable the writers to
conclude that: (1) affective disorders were frequently mistaken
for dementia praecox; (2) psychoses showing typical schizophrenic
development had recognisable benign features; (3) acute confusional
hallucinatory psychoses with fear were incorrectly diagnosed as
dementia praecox; (4) acute paranoia was a relatively common
psychosis; (5) the distinction between psychosis and psychoneurosis is
untenable. H. Devine.

(1) Psychoses and Influenza. [Psychosen nach Grippe.] (Monatschr. J.
Psych, u. Neur. 1919, vol. 46, page 267.) Hitzenberger , K.

(2) Psychoses associated with Influenza. (Arch, of Neur. and Psychiat.,

vol. 2, no. 3, September , 1919.) Menninger , Karl.

Observations on psychoses associated with the influenza epidemic of
1918. The material is divided into two groups—(1) cases in which
influenza was the direct cause of the psychosis, fever-delirium, and post-
febrile amentia; (2) cases in which the toxic condition aroused a latent
tendency to mental disorder. Naturally only the severest cases of delirium
came under treatment in the clinic and fifteen are included in this
study. The symptoms were confusion, terror, psycho-motor excitement,
and delusions of persecution and poisoning associated with hallucina¬
tions. The majority of cases were men ; the earliest onset was the
second day of fever and the latest the eighth; the prognosis in respect
to life was bad, 12 cases ending fatally, whilst the mental symptoms sub¬
sided with the fall of the temperature in the three cases which recovered.
Post-febrile cases numbered 30, the greater portion of whom were
women. The symptoms were association disturbances, confusion, and
hallucinations, and the psychosis began with sleeplessness, fatigue,
irritability and nocturnal hallucinations, some cases of short duration
remaining at this stage. The prognosis was good, and no case ended

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TREATMENT OF INSANITY.

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fatally. The interval between the fall of temperature and the onset of
mental symptoms varied from two to fourteen days. In no case was
the influenza the sole factor in the production of the post-febrile
psychoses. An hereditary factor could be excluded, but lactation,
pregnancy, alcohol, or malnutrition appeared as subsidiary causes. In
view of the relatively small number of psychoses in a widespread
epidemic the writer concludes that there must be an unknown causal
factor in these cases.

The second group includes cases of melancholia, mania, dementia
praecox, and delirium tremens, and in these cases the influenza is to be
regarded as the immediate influence which brought the latent psychosis
to the surface.

The second paper is a study of 120 cases at the Boston Psycho¬
pathic Hospital in which influenza was an apparent factor in the
production of mental symptoms. Southard’s eleven-group nosology is
adopted in grouping the cases. The conclusions of the author are
clearly seen in his summary by paradigms, exemplifying the psychiatric
effects of influenza, viz .:

(a) In the process of creation : normality -f influenza = delirium,
apoplexy, senile psychosis, schizophrenia, cyclothymia, hysteria.

(b) In the process of precipitation : predisposition -f- influenza =
delirium tremens, schizophrenia, cyclothymia, psychoneurosis.

( c) In the process of alteration : morosis + influenza = imbecility,
epilepsy + influenza = alterations in frequency and type, psychopathy +
influenza = psychosis, latent neurosyphilis + influenza = general paresis.

Influenza thus acts on the brain in three ways : to create psychoses,
to precipitate psychoses in predisposed subjects, and to augment or
alter their form when already existent. While we cannot regard
influenza as capable of qualitative psychic specificity, yet the quantitative
specificity is confirmed by its remarkable potency and versatility.

H. Devine.

4. Treatment of Insanity.

An Introduction to Psychotherapy. ( Edin. Med. Jourti., February , 1920.)

Robertson, George.

The author considers that pain and its analogues, malaise, discomfort,
ill-being, etc., whether of functional or organic origin, being forms of
sensation, are essentially mental phenomena arising in the brain, and
can be removed by psychotherapy. That the mind can act upon the
body and influence every function is a well-established fact. It is
possible, too, that certain organic changes, vascular disease, heart disease,
etc., may be traced to certain mental processes—anxiety—causing
excessive secretion by the adrenals. In every case of illness some of
the symptoms are due to suggestion either from within or from without.
This was seen in many of the “ slow recoveries ” in the war due to
auto-suggestion. In organic disease psychotherapy cannot effect a cure,
but in every case it can assist and give relief to suffering, e.g. pain in
cancer. In earlier days suggestion was employed unconsciously in the
use of charms, amulets, religious relics, etc., in later days in mind-cures

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and Christian Science. The relief of symptoms shows that faith alone
is a potent curative agent, and that the majority of the ordinary symptoms
are mental in nature and removable. The methods employed in
psychotherapy are suggestion under hypnosis, suggestion in the waking
state, persuasion and re-education, and psycho-analysis. In “ super¬
ficial ” cases immediate results often follow suggestion, but in the more
chronic cases the removal of a symptom by suggestion is often followed
by relapses, a new symptom taking the place of the rejected one, as
the underlying condition of morbid suggestibility has not been removed.
To overcome this condition Dubois introduced the method of per¬
suasion. He thinks that an appeal should be made to the intellect
by talks with the patient on the subject of his nervous symptoms.
Persuasion is to some extent a form of suggestion, as in all degrees of
belief feeling as well as the intellect is involved. Upon re-education
largely rests the completeness of the cure ; the connection between the
mental antecedents and the symptoms are explained to the patient;
when these are understood and acted upon his mal-adaptation ceases.
Freud has shown that the patient may be most profoundly influenced
by feelings and ideas of which he is quite unconscious. No persuasion
avails until the unconscious motive of his mental or nervous symptoms
has been uncovered. The process by which this can be done is known
as psycho-analysis. Three methods of probing the unconscious mind
are mentioned—the word-association test, the free association of ideas,
and the analysis of dreams. Psycho-analysis has its limitations. It is
not usually successful in curing persons above middle age ; even when
successful the treatment may take months. Robertson thinks that in
many cases it is unnecessary. No successful physician who has not
given attention to this subject has the faintest idea of the extent to
which he employs psychotherapy unconsciously. Every practitioner
and student of medicine must be taught the part the mind plays in the
chief symptoms of disease, and he must consciously use psychotherapy
in the treatment of these. His success will depend on the depth of
his convictions. C. W. Forsyth.

5. Pathology.

A New Method for the Estimation of Minute Quantities of Nitrogen
in Organic Substances, which Furnishes a New Quantitative Method
of Diagnosis in Some Cases of Mental Disease. (Report No. 2 from
the Chemical Laboratory , Cardiff City Mental Hospital.') Stanford ,
R. V.

The method employed consists of three stages: (1) The conversion
of the total nitrogen into ammonia by the Kjeldahl process; (2) the
conversion of the ammonia into pure aqueous solution; and (3) the
calorimetric estimation of the ammonia in this solution by means of
Nessler’s solution. The result is expressed as “nitrogen number,”
which denotes the number of hundredths of a milligramme in 1 c.c. of
cerebro-spinal fluid. In general paralysis there is a high nitrogen
number, which is marked towards the termination of the disease. It
may be low in the early stages or in remissions. In mania the nitrogen
number is always low—a factor of diagnostic importance in distinguishing

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between this disease and maniacal phases occurring in general paralysis.
In imbecility, dementia praecox, paranoia, amentia and epilepsy the
nitrogen number varies, but is usually low, and in terminal dementias
it is very high. It was also found that density and nitrogen numbers
run parallel to one another, with the exception of epilepsy, where high
density obtains. The author emphasises the fact that choline does not
occur in the cerebro-spinal fluid in mental diseases, and that ammonium
salts only occur in the merest traces. F. E. Stokes.

Hyperglycemia in Mental Disorders. (Brain, vol. 42 .pt. Hi, October 19
1919.) Koody, F H.

Hyperglycaemia is found in emotional states and may lead to tempo¬
rary glycosuria even in normal persons, and it may exist with normal
metabolism. It may be found in mental disorders with emotionalism
and the mechanism of its production is by stimulation of the suprarenal
glands causing hypersecretion of adrenalin, which circulates to the liver,
where more glycogen is mobilised and in consequence more glycose is
found in the peripheral blood. In this research Bang’s modified method
was used for the examination of the blood for glycose, and examinations
were made before breakfast and I hr., ij hrs., and 2$ hrs. after this
meal which consisted of 100 grms. of bread and 200 c.c. of milk. In
dementia praecox and epilepsy the blood sugar was found to be sub¬
normal before and slightly above the normal after breakfast. In dementia
paralytica and non-anxious melancholia the blood sugar was slightly above
the normal before and considerably above the normal after breakfast;
and in anxious melancholia the highest blood sugar content was found at
all times. In amentia, anxious patients showed a great increase of
blood sugar after breakfast as compared with non-anxious patients, and
in mania a similar increase was present in real emotional states, but was
absent in hypomaniacal forms in which the patient was only optimistic
and cheerful.

Cannon first suggested that hyperglycaemia might be useful to animals
in emotional states, as it provides the muscles with a larger amount of
sugar for combustion during the actions which follow or accompany the
emotions, i. e , fright or flight. This strong sympathetic impulse also
causes other reactions which are useful to the animal economy in such
conditions, viz., increased blood-pressure, widening of the pupil, erection
of the hair, inhibition of the salivary, sweat, lachrymal and gastric glands,
and of the motility of the intestines. Gaskell points out that both the
involuntary and voluntary nervous system can be divided into a somatic
and splanchnic part—the former, represented by the thoracico-lumbar
outflow of the sympathetic division, supplies the heart, blood-vessels, and
skin musculature throughou t the body: the latter, consisting of the bulbar
and sacral outflow, motivates the muscles of the alimentary canal. In
emotions of rage, fear, etc., when the animal had to flee or fight, the whole
somatic nervous system both voluntary and involuntary would come into
action.

Cannon’s theory affirms physiologically Gaskell’s anatomical concep¬
tion. In melancholia with anxiety and in the manic-depressive psychosis
we find symptoms of stimulation of the sympathetic analagous to those
produced in animals by fear and anger. These bodily changes depend

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on the highly emotional character of this disease. Now, the emotions
of a depressive character are phylogenetically spoken old and have been
provided with the bodily reactions which are useful to the animal in
attack, defence, or flight. The manic-depressive psychosis occurs with¬
out any apparent corporeal or psychical reason. The author suggests
that phylogenesis would help us to find the deeper ground of this disease.

F. E. Stokes.

The Rdle of the Pituitary Gland in Epilepsy. {Arch, of Neur. and
Psychiat ., vol. 2, no. 2, August , 1919 ) Tucker , B. R.

The writer regards all convulsions accompanied by unconsciousness
as symptoms of some underlying state or disease, and he believes that
epilepsy is an organic condition due to definite pathologic cerebral tissue
changes. Morbid conditions of the pituitary gland are found in a number
of cases causing a change in its secretion. The investigation of 200
cases of epilepsy by roentgenographic examinations revealed some
evidence of pituitary disturbance in 31 5 per cent. Some of these showed
evidence of syphilis or other disorders and 14 per cent, were regarded as
pure pituitary cases. From his observations the writer concludes that
there is a definite relation between the undersecretion of the pituitary
gland and a group of convulsive attacks usually termed epilepsy ; that
this group is divided into a chronic hypopituitary type and a transitional
hypopituitary type by both clinical and roentgenographic evidence; and
that pituitary gland feeding has a markedly beneficial effect, not
infrequently leading to a cure. H. Devine.

6. Sociology.

(1) The Criminal as a Patient. {The Dublin Journ. of Med. Sci.,

January , 1920.) McQuade , C. E.

(2 ) A Survey of 2,500 Prisoners in the Psychopathic Laboratory at the

Indiana State Prison. {Journ. of Delittq., January , 1919.)
Bowers , Paul E.

(3) Psychiatric Arms in the Field of Criminology. {Ment. Hyg. y

October , 1918.) Glueck , Bernard.

The first paper deals with the causes of crime, the anatomical ab¬
normalities found in criminals, and the method of treatment best
calculated to enable him to adjust himself normally to the outside
world on his discharge. A criminal act is defined as an act which does
not conform to the standard of conduct accepted by the age in which
the criminal is living. The author divides criminals into the following
classes: (1) The political criminal; (2) the criminal by passion
whose crime may be the only one in his life; (3) the insane criminal,
many of whom have been punished for their madness by being sent to
prison; (4) the instinctive or born criminal; (5) the professional
criminal who deliberately chooses his mode of life; (6) the occasional
criminal.

The causes of crime are divided into the following three broad
classes : “ (1) All the influences of the external organic world, the most
important of which are the influences of temperature and climate.

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312 EPITOME. [July,

is a heterogeneous mass of individuals, who demand different varieties
of treatment, and not the single remedy of punishment and imprison¬
ment so long meted out to criminals by society. As regards the
physical side, many cases of acute and chronic gonorrhoea, chancroid
and syphilis are received. These cases are quarantined in the venereal
department, and when fit for discharge are again classified and sent to
the divisions suitable for them. The chronically diseased and senile
persons are sent directly to the convalescent section. The normal and
slightly defective prisoners are sent to work in the shops, on the prison
farms and elsewhere. The prison hospital has four divisions—medical,
surgical, psychopathic and tuberculous. The insane individuals are
transferred directly, after examination, to the hospital for the criminal
insane. The author believes that there is a causal relationship between
purely physical defects and crime, although these may exist purely as
concomitant incidents. He states that the criminal act is the result of
a triad of agencies, namely, social conventions, economic conditions,
and the individual’s own physio-psychical organisation. Prisoners as a
class are more physically defective than the average citizen. In the
author’s 2,500 cases the physical condition was good in 1,435, fe> r * n
664 and poor in 401. Some were received in advanced stages of
tuberculosis, whilst many cases of this disease developed while in prison.

Cardiac lesions, arterio-sclerosis, nephritis, states of malnutrition,
dental caries, pyorrhoea, phimosis, defective hearing, defective eyesight,
adenoids and enlarged tonsils are common. Physical stigmata are
present in a large percentage of cases. These are found in defective
states of mind, which hinder the individual in adjusting himself to his
environment, and this maladjustment frequently gives rise to criminal
tendencies.

Tables of statistics are given dealing with the social life of criminals.

Employment: Employed, 1,394. Idle, 1,106. About 75 per
cent, of the prison populations is composed of persons who have no
skilled trade. The average wage income is to be classed at the lowest
wage-earning scale. Thievery, hishonesty and beggary go hand in hand
with a lowest wage earning-capacity. Prisoners on the whole are
untrained in mechanics, and are unlettered, shiftless, improvident and
irresponsible.

Associates : The influence of vicious associations can hardly be over¬
estimated as a factor contributory to crime. 310 of the cases claimed
good associates, 1,250 mixed, and 940 bad.

Age: There are more criminals between the ages of 20 and 30 than
of any other age. Old age, however, is not free from crime, especially
of a sexual character. Religion: 90 per cent, of these prisoners professed
belief in some organised religion. The average prisoner is a religious
man, those religions which are especially rich in symbolism appealing
to his nature. Some of these “ devout ” men are guilty of the most
dastardly sexual crimes. We must use religion in dealing with prisoners,
as it is a great element in ordering human conduct and serves better
for the suppression of crime than any police system. Tobacco : Prisoners
as a class are inveterate users of the weed, but probably not to any
greater degree than unconvicted persons. Hereditary taint. As to
whether criminal traits can be inherited is still an unsolved question.

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The author’s studies have shown, however, that criminality is indirectly
inherited by reason of the fact that insanity, feeble-mindedness, epilepsy
and other forms of psychopathy are inheritable conditions, and these
states are patent in the production of crime. Alcoholic liquors : 2,075
of the cases drank to excess. It is not possible to say just how much
crime is due to drinking. Alcoholism is often an expression of a defect,
a contributory factor to the crime rather than the immediate one.

The author deals seriatim with epileptic insanity, paranoia, general
paresis, cerebral syphilis, manic-depressive insanity, dementia praecox,
senile psychoses, puerperal insanity, hysterical insanity, psychopathic
personalities, constitutional inferiors and feeble-mindedness and their
causal relationship with crime. The types of criminal acts most
commonly found as expressions of the several psychoses are given.

In the third paper Glueck suggests that psychiatrists should undertake
to furnish the fundamentals for a dependable science of criminology.
The first aim should be to look beyond the immediate criminal act for
the solution of the problem created by it to the human being back of
the act. A psychiatric study of a criminal should supply at least the
following information:

“(1) A definition from the psychiatric standpoint of the type of
problem presented by each case. (2) A scientific analysis of the various
causative factors operative in a given case. (3) An outline of the most
promising plan of treatment for meeting at the same time the needs of
social security and the individual prisoner’s reclamation.”

The most intimate understanding of the criminal lies in the
analytic and interpretative approach. The seriousness of the criminal
problem lies in the large amount of recidivism. The problem involves
questions of human nature, of living forces which demand under¬
standing before they can be properly directed. It may be a purely
medical problem, or it might primarily be a sociological one, demanding
attention to some crime-provocative social situation; it may be one purely
for judicial administration, as in the case of the bank-wrecker. Glueck
is not opposed to punishment per se, but it should only be used as a
means to an end and not conceived to be the end in itself.

The subject of causation is still immersed in obscurity, and a note
of warning is given against assuming a cause and effect relationship
where only coincidences exist. The criminal act can only be viewed
as a reaction on the part of a particularly constituted personality to a
particular stimulus, internal or external. The results of treatment
have shown that the traditional attitude of hopelessness is neither
scientific nor correct.. The mere fact of recidivism has been taken as
a proof of irreformability: ample proof exists that such is not the case.

The authors of these papers emphasise the fact that in attempting
the proper understanding of the criminal the approach should be along
individualistic lines by a medical man trained in criminology, and that
an effort should be made, not only to safeguard society, but to enable
the criminal to effect a readjustment so that he may become a useful
member of society. C. W. Forsyth.

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7. Mental Hospital Reports for 1918.

Some English and Welsh County and Borough Mental Hospitals.

Bedford , Hertford and Huntingdon County. —It is not often that much
literary merit characterises a visiting committee’s report. The civil
services have a jargon which is not so murderous to the King’s English
as that used in business circles or so pedantic as that which dis¬
tinguishes army communications. The report under review is one of
the exceptions, and though it opens with all due form and stateliness,
comments like these are found :

“ Like 1915, this has been a year of transition, in which the opportunities of
peace are wanted to make up the arrears of war time. Every effort has been made
to adapt the resources of the establishment to this state of things.

“ The private patient scheme, which has so often flitted across the pages of these
reports, only to pass into some promised land more shadowy than itself, is at last
taking a tangible shape—a shape that could not be thought of while the asylum
was very full of patients sent in from other asylums used for the wounded.”

“ The rate of maintenance has had to be raised to the high figure of 19s. 3<f. It was
absolutely necessary in the interests of every ratepayer, since they are compelled
to take out-county patients who are sent from asylums closed by war at the same
rate (subject to a trifling difference) as their own home county patients. To lose
money oh the latter is merely a matter of account, but upon the former the loss is
permanent.”

We are not so sure about the former of these conclusions. Could
not a ratepayer refuse to subscribe to a rate covering expenditure for
an expired period and not the one for which it is raised ? Dr. Fuller’s
report is not wanting either in fluency of expression :

" It is also of some interest and perhaps of a little importance at the present
time to call attention to the increase in the percentage of cases of mental disorder
ultimately attributable to another cause, namely, syphilis—a fourfold increase in
the course of four years. It is not, however, to be assumed that such occurrence
necessarily indicates a general increase in the prevalence of syphilis throughout
the community. It does, however, help to bring its existence within the field of
vision and to emphasise the necessity of careful and prolonged treatment during
the earlier stages of the disease, treatment persisted in not only until all outward
manifestations of the disease have disappeared, but until the blood and body fluids
are pronounced after expert examination to be free from contamination. Under
treatment the abatement of physical suffering and the disappearance of outward
signs of the disease often lead the patient to the conclusion that he is cured and
induce him to discontinue treatment. Many years—even thirty years—later the
disease may insidiously reassert itself in a new garb, or as a result of severe mental
stress or mental or physical shock (of which there has been no lack during the war)
precipitate the patient into that most pitiful of all conditions, general paralysis of
the insane. In the meantime he has been apt to beget deformed and debilitated
offspring, who themselves are not unlikely to develop into general paralytics with
the onset of adolescence.”

The following paragraph will be read with interest, though this is not
the earliest or the only instance of the employment of female patient
labour on the farms :

“ During the summer a useful experiment was made in the employment of
female patients in agricultural labour. Some thirty patients were employed in
pulling linseed, a crop which had not previously been grown on this estate. The
satisfactory yield of 24 bushels of linseed to the acre was obtained and is proving
a valuable substitute for oil cake in the feeding of milch cows. I trust in the
future it will be possible to bring an increased area of land under crops suitable
for female labour.”

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No less than thirty-two pages and two tables are devoted to the accounts,
■which appear to be a fairly complete statement. There is a loss on the
farm of ^2,052 gr. 3d. The loss on maintenance account was increased
from £1,265 13^. 10 d. to ^3,884 12 s. 9 d. During the year the balance-
sheet provides £ 7,070 3*. 5 d. to the credit of maintenance and the
^4,859 os. 5 d. due to the Treasurer.

Birmingham. —At the time this report was made, the 1st Birmingham
War Hospital (Rubery) was being demobilised, while the Birmingham
Special Military Surgical Hospital (Hollymoor) was to continue for a
further period expiring not later than March 31st, 1920. A letter from
the Army Council thanks the Committee and Staff for their patriotic
action and devoted services. A well-deserved tribute is paid to the
work of Lieut.-Col. A. C. Suffern, R.A.M.C., during his 34 years’ service
as Medical Superintendent, four of which have been spent as
Administrator of the War Hospital, and whose early resignation is
foreshadowed.

Dr. Roscrow, in his report for Winson Green, records a decrease in
male admissions and an increase as regards females. Confusional
insanity was diagnosed in 277 per cent, of the admissions as against
181 per cent, melancholia and 17 per cent, mania. This is interesting
in view of the preponderance, with the exception of heredity, of alcohol
as a cause, the high recovery rate of 33^34 per cent, on the direct
admissions, and the fact that fully a third of the total deaths occurred
in those recently admitted with advanced bodily diseases, notably
phthisis. The death rate, 27’ 14 per cent, on the average number
resident, though still high, was less than in 1917 when it rose to
31'28 per cent.

The building fund account has ^12,500 invested in 5 per cent. War
Bonds 1922, while the balance transferred to the fund from general main¬
tenance transactions, covering ^91,841 ir. $d., was £1,972 13*. 10 d.
The assets in excess of liabilities was ^19,350 14 s. sd., of which nearly
^14,000 was represented by value of stock in hand, while the balance
at credit to the building fund account was ,£15,301 0$. lid. The farm
profits for the year amounted to .£247 1 is. 1 id. The financial position
is good and the accounts are presented in a singularly lucid
manner, but the farm account is not published. The weekly cost of
maintenance per patient is not stated, but in the Commissioners’
report it is stated that the maintenance charge per week was 18.1.

Brighton Borough. —Although the death rate per cent, on the average
daily number resident was considerably below the 20^3 per cent, for all
the county and borough asylums, being only 16 percent., that for males,
26 ’s per cent., was above 25-2 per cent., the average, while the female
death rate was only 8'6 per cent.

Regarding this Dr. Planck reports :

“ The death rate for male patients has been exceptionally high, chiefly on account
of the large preponderance of old and debilitated patients amongst the recent male
admissions, but overcrowding and lowered vitality as the result of malnutrition
»have contributed to this result.”

The increased numbers, however, due partly to the need to provide

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accommodation for patients from asylums vacated for war purposes,
enabled the borough rates to be relieved during the year to the extent
of £2,368 85-. 1 id., the cost of ordinary repairs, insurance, and super¬
annuation allowances. The total savings from this cause since 19 n
has been £14,472 os. 7 d. The farm and gardening account showed the
healthy balance of £1,219 1 6s. 8 d.

The death of the Rev. E. R. D. Litle, chaplain for 25 years, was
deeply regretted by staff" and patients alike.

Bucks County. —We congratulate the Committee and Medical Super¬
intendent of this Asylum on its excellent war record. From the report
of the Visiting Commissioner we gather that the male nursing staff
numbers 7 charge attendants and 17 ordinary attendants, 24 in all. Out
of those who were in the asyium service before August 1st, 1914, 17
joined the forces, or 70 per cent., one of whom was killed in action. Of
those who joined the asylum service since, no less than 19 left for
military service, out of whom 7 were killed in action. Dr. Kerr must
have had an anxious time with such a diluted male staff, and during the
year under review had in addition to combat a severe epidemic of
influenza which affected 200 of his patients and staff, in which he lost
22 of the former and 4 of the latter, including Dr. T. S. Logan, the
Assistant Medical Officer. The death rate was the highest recorded in
the whole history of the Institution, being 34'5 per cent, of the daily
average number resident. The increase of tuberculosis was remarkable,
accounting for 65 deaths as compared with 19 during 1917. It is
interesting to note that there were only 3 cases of colitis, 2 of whom
died. There were other worries inasmuch as 5 births occurred
during the year. No doubt Dr. Kerr rejoiced when the war terminated.

It was on the initiative of the Chairman of the Committee, Thomas
Field, Esq., that the Conference of Representatives of Visiting Com¬
mittees was held at the Guildhall on October 29th, 1918.

After transferring £460 55. 10 d. to the building and repairs fund, the
maintenance account showed a balance of ,£4,825 3*. 9 d. as against
£6,229 8s. id. at the commencement of the year. The value of stocks
in hand was ,£"3,226 7 s. 5 d. Thus the available cash balance is £"1598
16s. 4 d., on transactions covering over £40,000. It is advisable to
keep a good balance in hand in these days of soaring prices, for it
may be doubted whether it is legal for a county authority to recover
from the Poor Law authorities money to pay off" liabilities it has not met
by cash in reserve and the rate charged during the period incurred.

Canterbury Borough. —If this Institution can be taken as an example,
the smaller mental hospitals scored during the war. The recovery rate
was 36’36 percent., and the death rate only 10 percent. The borough rates
were relieved entirely of any charge in the building and repairs fund,
total expenditure on this account being £718 is. 3d., which was more
than covered by £1,000 from excess weekly charge on out-county and
private patients. The balance against the farm was £92 14s. 4 d.
The weekly maintenance rate per patient was 22s. n\d., 8s. of which
is accounted for by provisions. Of necessity, smaller institutions are
more costly owing to establishment charges being high in proportion to-

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patients, and the same can readily occur in very large institutions.
From an economical point of view a happy medium is possible which
unfortunately is rarely in accordance with the needs of the district.

Carmarthen , Cardigan and Pembroke Counties .—When compared with
Birmingham (Winson Green) there is a remarkable difference in the
form of mental disorder on admission. Out of the 133 cases admitted
from these three Welsh counties to Carmarthen Asylum none suffered
from confusional insanity, only 5 from general paralysis, and no less
than 103 from the pure psychoses. The principal causes recorded are
heredity, previous attacks and mental stress. Toxaemias and physical
stress are not so potent as in the manufacturing districts.

The death rate, contrary to most mental hospitals, was considerably
higher as regards females than males, being 19 74 per cent, for the
latter, 28'8 i per cent, for the former, and 24^8 per cent, combined.
Reference to the death table shows considerably more deaths from senile
decay and enteritis among the females than males. According to the
same table in no case was the cause of death verified by post-mortem
examination.

Out of the ninety-eight county, district and county-borough asylums
only in four does the female death rate exceed the male—namely,
Carmarthen, Cumberland, Lincoln (Kesteven), and Suffolk, and in one,
Northumberland, they are practically equal. This is possibly accounted
for to some extent by the degree of prevalence of general paralysis.

It is rather difficult to know why this mental hospital publishes its
accounts in the form it does. No doubt there is some good reason,
but in comparison with the simple statements found in most mental
hospitals’ reports, the Carmarthen statement is difficult to follow. The
accounts comprise an abstract of the income and expenditure, a
maintenance revenue balance sheet, the farm and garden account,
the building and repairs fund accounts followed by a balance sheet.
This is in addition to the usual financial statement, Parts I, II and
III. Much of the detailed income is repeated in the maintenance
revenue balance sheet. This gives under receipts from farm and
garden account ^805 y. 2d., and the total, less the balance at the
commencement of the year, agrees with the income given in the
abstract of the income and expenditure. The balance in favour of
the farm is ^1,254 6 s. 8 d. in one farm and garden account, and
^1,043 17 s. 7 d. in Part III financial statement. It is impossible to see
how the sum transferred to maintenance revenue is arrived at. In
Part I financial statement credit for supplies to the hospital from the
farm does not appear, and the .£144 ioj. 7 \d. balance in hand
apparently cannot be reconciled with the maintenance revenue balance
sheet. No doubt all this can be explained, but some rearrangement
of the form in which the accounts are presented seems desirable if they
are to be understood by other than skilled accountants. The statements
made in the bulk of the mental hospital reports can be readily followed,
and the financial position is made clear at a glance.

Croydon Borough. —Dr. Pasmore devotes nearly two pages of his report
to a description of the medical work carried out by himself and his one

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assistant. The sum of money saved by the absence of other colleagues
is estimated, the number of ward visits, emergency visits, night calls, and
special visits for new admissions are detailed. Other paragraphs deal
with the number of patients re-certified, number of prescriptions written,
pathological examinations undertaken, letters written regarding patients,
letters read written by patients, interviews granted and statutory clerical
books kept, etc., and consultations and affidavits are not omitted. Some
time also must have been taken in compiling these figures, which form
instructive reading. It is the first time we have ever seen a statistical
summary of the work involved in the routine care and treatment of an
average of 680 resident patients, and we are grateful, as no doubt his
committee was, for the information afforded. It should be useful
elsewhere in persuading those committees who tend to be sceptical
regarding the onerous duties of the medical staff.

Dr. Pasmore has to be congratulated on a fine recovery rate which
has averaged during the past ten years 40‘89 per cent, in the case of
females and $2'o$ per cent. in the case of males. Regarding the year
under review he states:

"Although the discharge rate was somewhat lower than in past years yet of
those discharged recovered during the year not a single case relapsed, showing
that the treatment received was having some permanent effect.”

It seems rather early to prophesy.

The death rate during 1918 calculated in the average number
resident was 30 - 48 per cent, males and 15.52 per cent, females—total of
20 per cent. This is the highest recorded for ten years, being almost
double the average.

Regarding the year’s finance Dr. Pasmore reports :

" I am very pleased to state that the maintenance rate per head per week for the
past year has worked out at 18s. 8 d. This is much below the cost in other
Metropolitan Asylums. Great economy has been exercised and the numbers of
private patients have also materially helped to reduce the rate. At some asylums
the rate I hear has been as high as 24s. per head per week, and if we had worked
at this level, with an average of 680 resident, we should have spent nearly ,£10,000
more.”

In defence of these less fortunately managed institutions, a quotation
from the auditors’ report for the same year might be given, showing that
Dr. Pasmore is approaching dangerously near the 24 s. per head per

week.

“The average number of patients for the quarter ending March 31st, 1919, was
690, and the average cost per head per week 21 s. 10 id. For the corresponding
quarter ended March 31st, 1918, the average number of patients was 691, and the
average cost per head per week 175. 8d.”

The maintenance account showed a deficiency of ^2,589 17^. 2 d.
there being an increase in all items of expenditure except the
amusement of patients, upon which a saving of £^38 was effected.
There is a bank overdraft of jQ 3,373 7 s. 8 d. The net loss on the
farm was ^521 is. od as compared with £^241 12J. 4 d., the loss
during 1917. The profit on private patients credited to the building
and repairs fund was £1,212 os. 6 d. The number of private patients -
resident was hi, of whom 14 were service patients. In this con¬
nection it is interesting to note that 17 patients were boarded at

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Netherne at a rate of 21 s. per week. The total income from private
patients was ^8,243.

Derby Borough .—The year 1918 completed the third decade in the
history of this hospital. Dr. Rutherford Macphail, as in 1898 and
1908, summarises the statistics for the decade and compares them
with the previous decades. It is both instructive and interesting, so
we reproduce almost verbatim.

Total General Results during the Three Periods of Ten Years.

Ten years ending 1898. 1908. 1918.

Admissions.988 1,096 1,081

Recoveries.365 364 307

Deaths.337 329 520

Percentage of recoveries on admissions . . 36 9 33 2 28 4

Percentage of deaths on numbers resident . . n - 9 100 n'2

Summary of Admissions.

In the last ten years 1,081 cases have been admitted; of those 125 were re¬
admissions so that the admissions represent only 956 individuals. The 125
re-admissions represent 85 persons; of these 68 relapsed after recovery, and 17
•came back after discharge to the workhouse or to care of friends. This gives us
the following ratios:

|Ten years ending

1898.

1908.

1819.

Percentage of total re-admissions (cases) to

total admissions .....

127

ii *5

Percentage of total re-admissions (persons) to

total admissions.

7'5

102

Percentage of cases relapsed after previous

recovery .

6’2

Percentage of unrecovered cases re-admitted

i'S

The interesting point brought by out these figures is that contrary to what might
have been expected, vi», that one would naturally look for a larger percentage of
relapses after recovery in each succeeding decade, the ratios in the third are
smaller than in the second decade, and are practically the same as the ratios in the
first decade.

The percentage to the total admissions of six clinical varieties of mental disease
in the three decades are as follows:

Ten years ending

Percentage to
total admissions.
1898. 1908. 1918.

Recent mania.

176

23 ''

164

Recent melancholia.

132

16-5

16 7

Senile insanity.

Congenital insanity.

Epileptic insanity.

109

5'9

General paralytic insanity ....

These account for rather more than three-fifths of the total admissions, the
remainder being chiefly cases of chronic insanity. In contrasting the three periods
the most noteworthy points are these : the ratio between the cases of mania and
melancholia have altered in the third decade, so that they are practically the same
instead of the maniacal cases preponderating as in the first two decades ; there is
a marked increase in cases of congenital insanity, and a decrease in cases of
senility, epilepsy, and general paralysis.

Summary of Discharges.

The total number of cases discharged has been 451, of which 307 have recovered,
43 were relieved, and 101 were discharged as not improved. The recovery rate on

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the total number of admissions was 28'4 per cent., or excluding the transfers from
other hospitals, who were nearly all chronic cases, 38 - 3 per cent. The corresponding
figures for the first io years' summary were 36‘9 and 46 - o, for the second io years'
summary 33^2 and 2 ^' 3 -

Summary of Deaths.

The deaths numbered 520, or ii‘2 percent., calculated on the average number
resident each year. The proportion was considerably higher on the male than on
the female side, and the total number of deaths exceeded the number of discharges
for the decade, in marked contrast to the proportion in the two previous decades.
Forty per cent, of the primary causes of death were due to cerebral and spinal
diseases; also in a disease like general paralysis, which accounts for more than a
third of the cerebral deaths, there were 60 cases among men, as compared with 19
female deaths. The percentages from the six most frequent causes of death are
as follows:

Ten years ending

1898.

1908.

1918.

General paralysis

2218

2370

«S'i 9

Epilepsy.

1656

790

592

Cerebral softening

7 ' 4 i

668

5 ’ 9 6

Senile exhaustion

• • 11 S 3

1003

11 '34

Phthisis pulmonalis

976

4-86

1P92

Heart disease ....

590

1185

903

Two of the causes of death, namely, cerebral softening and senile exhaustion, do
not vary much when the three decades are compared. Deaths from general
paralysis and epilepsy are less numerous, deaths from heart disease have increased,
but to a less extent in the third than in the second decade, while deaths from
pulmonary tuberculosis, reduced by one-half in the second decade, have again
increased in the third decade.

Dr. Machpail deals also at length with the statistics of Derby patients
only and also with the financial history of the Institution.

The total capital outlay, including everything, now stands at .£76,095,
of which £50,101 has been repaid, the balance of loan outstanding
being £25,994. The Institution has justified its existence, not only by
the value of the medical work done, but by saving the borough the
expenditure of £76,713 with nothing to show for it. By the decision
to have an asylum of their own, the Corporation will have to their credit
for approximately the same expenditure when the loans are repaid a
fully equipped and well-managed modern mental hospital, together
with the cost of the care of their patients for 30 and more years.

This being Dr. Macphail’s Thirtieth Annual Report we venture to offer
our congratulations on a record of valuable services to the public and to
the mentally afflicted which he can well be proud of.

Dorset. —Dr. Peachell states the case for the attachment of out¬
patient cliniques and mental wards to general hospitals as follows :

“The general public need enlightening to realise that mental disorders are not
something different and apart from ordinary diseases to be viewed as a stigma on
the family, but are often associated with, or caused by, diseases, such as syphilis,
influenza, tuberculosis, alcoholic poisoning and other toxic conditions, and that to
promote rapid recovery skilled treatment in suitable environments should be started
at the earliest possible moment.

“ When this is realised and the Lunacy Acts amended—and there are good hopes
of this in the near future—it will be possible to establish a system of out-patient
clinics and mental wards attached to all general hospitals of any size to which
patients may come without delay for advice and treatment in the early stages.

“ The recovery-rate has been very high in the treatment without certification, ia

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special war hospitals with highly trained and adequate staff, of the large number of
soldiers broken down mentally owing to the stress and the diseases incidental to
war.

“In these hospitals the great aids to recovery are—

“ (1) Early skilled treatment, including psycho-analysis.

" (2) Freedom from certification.

" (3) Much liberty, parole being freely granted.

" (4) Knowledge that their trouble was understood and that they could get the
help of not only mental experts, but of the physician and surgeon for
their physical diseases or supposed diseases.

“(5) Non-association with chronic cases.

“ Surely civil patients should have similar opportunities for early skilled treatment,
which in very many cases would avoid the necessity of legal certification and often
life-long mental disablement to the great cost of the ratepayers. The present
mental institutions would then only have to deal in the main with chronic cases
and those in whom there was little chance of recovery.”

Though this is admirably put, yet our optimism does not carry us
quite so far. It is inconceivable that no recent cases will need
certification or forcible detention in some form, and we see no likelihood
of the creation of sufficient cliniques throughout the country to deal
with all freshly occurring cases of mental disease. It is more likely
that there will be a greater co-ordination between general hospitals and
the mental hospitals, with out-patient departments and mental wards
reserved for non-certified cases in the former, the overflow passing on to
the latter together with those needing certification. No doubt in the
big centres special cliniques for both out-patients and in-patients like the
Maudesley hospital will be established, where, in addition to voluntary
cases, certifiable cases not unduly prolonged will be treated. In many
instances, owing to their situation, mental hospitals will need to have
attached to them special cliniques, failing a suitable general hospital
being available for this purpose. The future of the present mental
institutions is not so black as painted by Dr. Peachell, and when
voluntary borders can be received there is no reason why all or most of
the advantages of the special war hospitals should not be obtainable
at the former. As regards the treatment of recent cases, many
summers will pass before the new methods of dealing with curable
cases will result in the mental hospitals becoming entirely chronic
asylums, and then probably only in a few instances will it occur.

Regarding the occurrence of enteric fever, which affected 26 patients
with four deaths and six of the staff with no fatal results, Dr. Peachell
says:

“ I still am convinced that the chief cause of cases are unknown carriers and
direct infection cases from these. All cases occurring are now treated and after¬
wards kept in special wards.”

Mr. Trevor in his report states that:

" Apart from the possibility of carriers in the different wards and direct contact
cases, appearances seem to point to the possibility of infected vegetables from
sewage percolation."

The committee have in hand a complete scheme for the disposal of
sewage effluent and its treatment by septic tanks and filters. The
private patients’ fund has to its credit £2,112 is. 4^., but the balance
on the maintenance account is only £588 5s. gd. No separate farm
statement is given.

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Bssex County, Brentwood. —Dr. Turner’s report of his administration
for the year as usual is brief, but this is more than made up for by
the clinico-pathological and pathological appendix, which, like its
predecessors, contains a valuable statistical record of the morbid changes
found post-mortem in the brain and other organs of those who had
suffered from mental disorders. It embraces no less than 221 post-mortem
examinations for the year, and there must be accumulating at Brentwood,
the outcome of Dr. Turner’s careful and painstaking investigations,
records which, when they come to be summarised and collated with the
clinical manifestations, will be a veritable gold mine of valuable informa¬
tion. It is hoped that some day this will be done so that this new source
of information will be rendered available to students and the psychi¬
atrical world in general. An interesting case is recorded, the cerebro¬
spinal fluid and blood being investigated by Sir F. W. Mott, which in every
way was a typical case of general paralysis, but turned out post-mortem
to be one of meningeal syphilis, which under salvarsan treatment might
have cleared up and been considered as a successful instance of the
cure of general paralysis. This and similar instances raise the question as
to whether all cases diagnosed as general paralysis should not be treated
on the chance of in reality being cases of this kind and so obtaining relief.
We gather from the report that there has been no recurrence of the ex¬
tensive epidemic of enteric fever which prevailed during 1917. This is
another mental hospital where prophylactic treatment by anti-typhoid
inoculation has been carried out, which together with other pre¬
cautions seems to have been effective in stamping out the disease.

The Commissioner reports that—

“ Measures tor dealing with soiled linen are now in full working. Such linen is
at once placed in trolley tanks containing creoside, to which it is conveyed from
the upper floors in zinc buckets containing the same disinfectant. The trolleys are
wheeled direct into the foul wash-house, and the linen then received into a large
collective tank of creoside—before being dealt with in the laundry. All the patients
employed in laundry-work are systematically drilled for ablution of hands before
meals and at the close of the day’s work. I was present on the latter occasion
yesterday, and satisfied myself that this prophylactic measure was properly and
thoroughly carried out."

Dr. Turnbull at Colchester lays great stress on the importance of a
trained nursing staff:

"Great credit is due to the medical officers for the number of lectures that
have been given to the staff during the war, but it has been quite impossible to
provide adequate instruction. There are few diseases so dependent for their
amelioration on patient and intelligent nursing as insanity, and yet the standard of
nursing in mental hospitals leaves much to be desired. It is essential for the
welfare of the patients that promotions and salaries should depend, not on long
service, but on knowledge and efficiency in all branches of the service."

It is to be hoped that the day is not far distant when mental hospital
rules everywhere will make it impossible for probation nurses to hold
responsible positions until fully trained. The difficulty at present is to
obtain suitable candidates for training to meet the many vacancies the
outcome of the recent war.

The financial statements of these two hospitals under the same county
authority show this difference: whereas Colchester, though the
hospital commenced with a balance on maintenance of ^6,637 8 j. 4 d.

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MENTAL HOSPITAL REPORTS.

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at the end of the year has .£4,280 i6r. 9 d. to its credit, Brentwood,
already in debt to the extent of £14,365 17 s. 3^., increased its indebted¬
ness to £18,499 l2S • 9 d.) but the building and repairs fund and the farm
accounts of both institutions have handsome credit balances.

Exeter City. —Dr. Bartlett has had a trying year, and has shown
highly commendable courage and endurance in meeting and overcoming
many difficulties and worries. The armistice only just saved him from
the upset and turmoil incidental to the asylum being converted into a
war hospital, for which he is no doubt thankful. His report exemplifies
the many-sided character of the duties which fall to the lot of a medical
superintendent of a mental hospital accommodating under 400 cases.
Regarding the increase in the number of deaths, although lower in 1918
than during the previous year, he says:

“ At this institution the chief cause has undoubtedly been the reduction in
quantity and'quality of the food. In addition to this must be mentioned the age
and physical standard of the patients admitted, the preponderance of an untrained
temporary staff, a mild degree of overcrowding militating against the proper
isolation and segregation of tubercular and infective cases in a hospital already
handicapped in this respect, and the prevalence of an epidemic of enteric fever.
There is no isolation hospital, and classification according to mental types, more
difficult at all times in a small than in a large hospital, clashes with the proper
segregation of infective cases and potential carriers of infective disease.”

This formidable list of additional reasons would seem to crowd out
the possible effect of the reduction in quantity and quality of the food.
We are almost tempted to agree with the Medical Superintendent of
Bexley that a good deal of nonsense is talked about the effect of war
diet in this connection. It is presumed that had the patients been
fortified by better diet to meet these adverse conditions, the increase in
the death-rate would have been largely averted. Let us put it in
another way. Was the diet in peace times so rich in essentials and
abundant in quantity that the patient could afford to do without a
preponderance of trained staff and endure a vastly increased risk of
acquiring dangerous infective diseases without an alarming increase in
the mortality rate ? It is hardly a matter we care to dogmatise on, yet
undoubtedly the view generally taken by medical superintendents
supports Dr. Bartlett’s contention.

The paragraph relating to the employment of patients is both in¬
structive and interesting:

" The average daily number of patients employed has been 182, or 55 per cent.
of the average number resident—330—which includes 80 private patients. Since
the transfer of the Barnstaple and Tiverton patients it had been impossible to keep
up the numbers employed on the farm, and latterly, owing to the increased leave
granted to attendants, it has been difficult to spare regularly suitable attendants to
take charge of farm parties. Supplying parties to outside farmers has been out of
the question, but occasionally trusted men are allowed to assist them, the farmers
fetching and bringing back the men."

Failing boarding out it seems possible that more could be done in
this direction with advantage to both agriculture and the patients’ health,
and some such scheme came into force as regards convalescent patients
in war hospitals. These precautions would need to be taken for the
safety and proper care of the patient and the liability of the farmer in
case of accidents.

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324 EPITOME. [July,

Regarding the continued prevalence of enteric fever, we con¬
gratulate Dr. Bartlett on adopting the only sound method of combating
the evil, pending the real origin of infection being ascertained :

“ Having regard to the continuance of the epidemic and the excellent results
obtained from preventive inoculation in the army it was decided to adopt this
procedure, and all the patients physically suitable under sixty years of age were,
therefore, inoculated in November and December.”

The following extract from the Commissioner’s report describes an
occurrence which fortunately most English asylums have not ex¬
perienced and trust to avoid for many a long day. Of all people to
suffer from industrial disputes every right-thinking man would say that
the sick and suffering, either in mind or body, should be the last.

“ At the present time the administration of the asylum is carried on with great
difficulty in consequence of a strike of the staff, male and female, which began on
Wednesday, the 30th ult. The immediate occasion was the refusal of the Com¬
mittee to reinstate a carpenter who had been dismissed for insubordination in
December. Out of twenty-two male attendants twelve joined in the strike, and out
of a like number of nurses, fifteen. In addition to these, thirteen male employees
and two laundry maids went out; the males including three out of six on the farm,
one out of four stokers, the kitchen staff, gardener, baker, two painters and
carpenter. There has been little difficulty in filling the places temporarily or
otherwise of the male staff, and there are to-day as many attendants on duty as
just befoie the strike; but it has not been so easy on the female side, which is
to-day nine short of its pre-strike strength. The strike left the female Infirmary
and the Refractory Wards and the male Acute and Epileptic Ward bare of staff;
there was danger of the milk supply being stopped, and the working of the laundry
and kitchen was placed in jeopardy; but with the aid of volunteers and others the
service in these departments has been carried on, and patients have been employed
to assist in the staff duties of the wards. It may be observed that the older and
more experienced nurses did not go out, and that the strikers included only two
nurses who joined in 1916 and two in 1917, the rest having been appointed in 1918
or 1919. It is satisfactory to report that the Medical Superintendent has been
able to meet the difficulties of the situation so successfully as appears to have been
the case.”

As the outcome of more humane methods the uniformed staff have
been given a 63-hour week inclusive of meal times, and a commencing
annual salary of ,£58 and .£33 for male and female nurses respectively.

No medical tables are given, but everything material in this connection
is detailed in the Medical Superintendent’s report—an admirable and
compact document which gives a bird’s-eye view of the state of the
institution, the work done, and the progress made during the year.

No balance-sheet is issued, but there is a healthy credit in favour of
the farm and garden of £1,469 135. 10 d. The maintenance account
commenced with an adverse balance of .£8,750 165. 9 d., which increased
to jQ 1 o, 175 u- 9 <l- at the end of the year. For a mental hospital of this
size the rate charged is low, being from 15^. 6 d. to 21s. per week.

Glamorgan (County ).—The outstanding feature of this report is the
complete set of medico-psychological tables prepared by Dr. McGregor,
the senior assistant medical officer. On careful examination of these
statistics no material facts are revealed which would show that the war has
had any effect either in the form of mental disorder or as regards its
recoverability. This has held good throughout the war. Interesting
information, however, can always be culled from these tables when

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compiled with conscientious assiduity as in this case. Table A4 shows
that the admissions for each year from 1864 to 1877 have been entirely
accounted for except as regards two cases in 1865, one in 1871 and
another in 1876. Thereafter the number of patients remaining for
each year varies from one to under twenty until 1897, since when it
gradually increases. During the year the sole remaining case admitted
in 1870 died, as did one remaining from the admissions of 1878.
Table B6 shows that the main admissions were soldiers and colliers as
regards the men, and housewives and domestic servants in the case
of the women. Tables B7 and 8 show that the main determining causes
were mental stress, critical periods, alcohol, syphilis and epilepsy.
Table B9 demonstrates that general paralysis occurred almost entirely
between the ages of 35 and 44. Tables C2 and C6 are indicative that
prognosis was good for two years from the date of onset in the majority
of the cases recovering, provided that admission to special treatment was
not delayed beyond six months. From Table C4 we gather that mental
stress produced the mental disorders most readily recovered from.
Table D3 records the existence of two imbeciles over eighty years of age,
and Table E reveals the saddest news of all—that the prognosis of
1,489 cases out of 1,658 is unfavourable.

A severe epidemic of influenza affected 362 patients and 125 members
of the staff with fatal results in 66 and 3 cases respectively.
Otherwise the death-rate would not have been more than the average.

The maintenance account commenced with a credit balance of
^3,012 ox. o d., which was reduced to £ 6 y 8x. o d. during the year.
However, the statement of the financial condition of this account
at the end of the year shows a balance in favour of the asylum of
£ 5,078 5X. id. after outstanding accounts have been paid and unpaid
amounts received. No balance-sheet proper is presented.

Hants County .—No district seems free from housing difficulties, and
the Committee are endeavouring to provide cottages for male staff
returning from the war who either gave up their houses on enlistment
or have been married since. Six cottages are in contemplation at a cost
of ^3,000. In 1914 the cost would have been ^1,400.

Dr. Abbott is not satisfied that the Board of Control’s requirements
as regards floor space for patients are sufficient:

" With respect to the figures given here, it should be borne in mind that they are
based on the Board of Control's minimum requirements of 50 sq. ft. per bed in
ordinary and 66 sq. ft. in infirmary wards. The Board have not altered these
figures in the last sixty years, arid in my opinion they are inadequate. The recognised
minimum space in ordinary hospitals is 8-900 cubic feet. Owing to the faulty
habits of a large proportion of asylum patients they require more space tha« sane
patients.”

In the Commissioners’ revised “suggestions and instructions,” 1911,
40 ft. superficial per patient for ordinary patients and 50 ft. for noisy
and turbulent cases is recommended for day-room space, and as regards
dormitory space 50 ft. superficial for each bed (single room 63) for
clean and healthy patients and 67 superficial for each bed (single room
■84) for hospital cases. The asylums taken over as war hospitals were
supposed to be capable of accommodating one-third more of the general

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hospital type of patients. It is to be remembered that a general hospital
standard of air space (65 sq. ft. for light cases, 85 sq. ft. for ordinary
cases and 144 sq. ft. for infectious cases) includes both day and night
accommodation, and having regard to this the Commissioners’ standards
are liberal in comparison. However, whatever standard is adopted a
6-ft. wall space for each bed should be insisted upon for comfort,
ease of nursing and prevention of infection.

Dr. Abbott has good reason to be anxious regarding overcrowding.
The Commissioner reports:

“ Dysentery has been endemic in the institution for very many years, but has
increased in incidence very markedly since the outbreak of war. During the twelve
years including and previous to 1914 the number averaged about 31 per annum ;
1915, however, showed 135 cases, 1916, 122 cases, and 1917 as many as 195.
Although there are signs of diminishing rate, the continued trouble is serious
enough to warrant all Dr. Abbott’s anxiety, and all the efforts he is making to
to arrest its spread.”

The accounts are very clearly presented. The balance in favour of
farm and garden is £2,868 6s. 4d., and the cash balance on March 31st
1919, is £3,499 17 s. 11 d. instead of there being an overdraft as
during the previous year. The balance in favour of maintenance is
£21,068 19*. 9 d., of which £10,921 5J. nd. represents value of stock in
hand.

Kent County, Banning Heath. —Dr. Wolseley-Lewis pays a graceful
tribute to his patients and staff in the following words:

"The declaration of an armistice on November nth will, we hope, soon bring
us permanent peace. For the last four years the conditions of life here have been
extremely trying for both patients and staff, and in their different spheres they
deserve commendation for the way in which they have adapted themselves to the
ever-increasing strain.

"Throughout the year we have suffered from a shortage of nurses, and I am
glad of this opportunity of placing on record the self-sacrificing devotion and
untiring zeal in the care and treatment of their patients, exhibited by those who
remained with us.”

He does not appear to have had time to refer to his own arduous
work, neither would his inclinations lead him to mention it. How¬
ever, members of the Association are well acquainted with it.

We are glad that another cause for the recent increase in tuberculosis,
other than war food and war conditions generally, has been found:

"The death-rate, ig'1 per cent. (males, 22 per cent.-, females, i 6 "j per cent.) is
the highest ever recorded at this asylum. This is due in part to war conditions, as
mentioned in last year’s report, and in part to the very severe epidemic in Novem¬
ber. This epidemic attacked 500 persons, and was not only directly responsible
for 56 deaths, but as a sequel caused a remarkable increase of active pulmonary
tuberculosis.”

The usual financial statement, Parts I, II and III, is furnished, but
no balance-sheet. The balance in favour of the farm is ,£1,036 5.1. 8 d.,
value of farm stock being £4,332 14J. 5 d., and the balance to the credit
of maintenance over £20,000. The weekly cost per head is 17 s. 3 d.

Kent County , Chartham Down .—The retirement of Dr. Fitzgerald
after many years’ service as medical superintendent is noted with an
expression of regret in the report of the committee. Dr. Fitzgerald
refers to it in the following words :

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“ During the twenty-seven years of my service here I have enjoyed the unfailing
support ot the committee and received much kindness and consideration at their
hands, and it is with many regrets that I find myself at the end of my official
relations with them ; at the end also of my association with the officers and servants
of the asylum, whose loyal and patient conduct through the war period was of
great assistance to the administration. My best wishes are with my successor,
Dr. Collins, and with the asylum for its welfare in the future under his
superintendence.”

For our part we wish both well. Thus it happens that the present
medical superintendents of the two Kent County asylums have been
recruited from the London County Council Service.

As regards mortality, no less than 45 per cent, of the deaths was due
to tuberculosis, associated in one case with general paralysis. Influ¬
enza only accounted for two deaths and the epidemic was of a mild
character. The financial position is similar to that at Barming Heath
but the weekly maintenance rate is 19 s.

London City .—The visiting committee is grateful to the City
merchants :

“ We have again to acknowledge the loyal manner in which we have been served
by many of the contractors. The inevitable difficulties which have from time to
time arisen in connection with securing adequate supplies have been successfully
overcome.”

There is no doubt but that in many instances the patients in asylums
during the war would have fared badly had contractors not paid due
regard to the claims of old customers notwithstanding the temptations
of new and lucrative markets. It speaks well for the fair dealings of
asylum authorities generally.

Dr. Steen as usual endeavours in his report to keep his committee
fully informed as to the trend of lunacy affairs generally :

“ It has been maintained in this report each year lately, that the war would cause
a decrease in insanity, and these figures are ample confirmation of the views
expressed. Various explanations have been given. One writer states that the
absent cases are to be found in the military hospitals ; but the board of control has
been at some pains to discover the numbers of such, and in the report quoted it is
stated that only between 2,000 and 3,000 “ mental and nervous” cases were under
observation in military hospitals. Furthermore, the decrease in the admissions
has not been confined to the male sex. For example, in 1916 the total female
admissions in England and Wales was 27 per cent, less than in 1915, and in 1917
2*i per cent, less than those of 1916.”

“Will the decrease in insanity be permanent? Without claiming the gift of
prophecy the writer is fain to believe that the future is brighter in this respect
to-day than for many years past. The influence of the Mental Deficiency Act
involving the control of defectives and the prevention of the propagation of their
kind, the control exercised over drink and venereal diseases and the better
housing conditions promised will all have a beneficial effect. These are
preventive measures. ”

We deal with this matter elsewhere, but not so optimistically. How¬
ever, we do not complain of Dr. Steen’s attitude, for surely it is the right
way to tackle difficult problems.

We are all with him as regards the following paragraph :

" As regards treatment, when the disease is threatened or established, there are
signs of a general awakening in the public mind respecting its responsibilities in
the matter. The cases of so-called 1 shell-shock ’ (which is really a form of
mental disorder) are teaching many that the sufferers from mental ailments, in

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place of being a subject of vulgar merriment or disgust, are worthy of all the
sympathy and help possible. It is but a step further, and a short step at that, to
actual insanity, and the harsh and obsolete lunacy laws which were made at the
instance of the public will be repealed only by their action. People require
educating, and it is hoped that the work of the Conference of Asylum Visiting
Committees, which holds its meetings at the Guildhall, and the publications of the
Medico-Psychological Association of Great Britain and Ireland will meet with the
success they deserve.”

This mental hospital was unfortunately situated as regards the
occurrence of air raids, and Dr. Steen has no doubt but that the health
of both patients and staff suffered as a consequence. He places on
record a well-deserved expression of admiration and thanks to his
staff for their fortitude on these occasions and also for the fine work
they did generally during the war.

No farm account is published. In the receipts and payments
account there is a cash balance in hand of ^3,821 igs. 5 d., while as
regards income and expenditure there is an excess of income of
^1,593 i8j. lod. The balance in favour of building and repairs fund
is no less than ^10,095 4*. yd.

Monmouthshire. —Dr. Phillips has had plenty to do with only one
medical officer to assist him in the care of an institution housing over
1,000 patients. Dysentery, enteric, and an epidemic of influenza increased
his burden of work, and added to his cares and responsibilities. His
committee have every reason to be grateful to him, and in their report
make a handsome acknowledgment of his services and also those of the
staff generally.

From the Commissioner’s report we gather that between February,
1918, and March, 1919, there occurred 105 cases of dysentery, and since
July 27 cases of enteric fever with fatal result in 7 cases. One
nurse also was attacked and died. Enteric contacts have been inoculated
with protective vaccine. The balance in favour of the farm and garden
is ^891 oj. 2d. Maintenance opened with an adverse balance of
^2,815 17$. o\d. excluding value of stock in hand, and closed with an
adverse balance of ,£2,768 6 s. 4 %d. However, the balance due to the
building account and the bank balance are very satisfactory.

Nnvport Borough .—An outbreak of enteric fever delayed and the
armistice finally prevented the conversion of this mental hospital into
a neurasthenia and shell-shock hospital.

In reporting the abnormally high death-rate Dr. Nelis says :

“ In addition to other causes more directly arising from the war, the death-rate
here has been affected by the occurrence during the year of a severe epidemic
of asylum dysentery, from which disease previous to the war this asylum had been
entirely free, and which was introduced by patients sent here from other asylums
under the necessity of war conditions.”

This is a regrettable occurrence, and likely to be a reminder of the war
for many years to come.

There was also an outbreak of enteric fever, the origin being un-
traceable.

Deposits in supply pipes and radiators caused the heating system to
fail, and for this reason it seems rather fortunate that the proposed

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conversion into a war hospital failed to materialise. The Commissioner
reports:

“ Unfortunately in the early part of the year, after having been in an unsatis¬
factory condition for some months past, the heating system completely failed, and
open fires had to be depended upon entirely for heating the wards. So far it has
been impossible to reinstate the heating, but orders have now been given to the
contractors, and it is hoped that all will be well again before next autumn.”

In addition to the usual financial statement Parts I, II, and III there is
given a combined payments and receipts and expenditure and income
statement both as regards maintenance and building and repairs fund.
This is a municipal way of presenting accounts and has much to
commend it. These two statements and the balance sheet convey a
clear picture of the financial position, namely, that the surplus of assets
over liabilities during 1918 has been reduced from ^£5,484 to ,£4,151
omitting the odd figures. Of the assets ,£3,418 is represented by
value of stock in hand—the rest is cash.

Salop County (including Borough of Wenlock). —Dr. Stanley Hughes
reports an unusual feature in the epidemic of influenza in November:

" Health of the Asylum .—Under this heading the outstanding feature of the year
has been the influenza epidemic, which visited the asylum with great severity in
November last, when a large proportion of the staff and male patients were attacked
by a very severe type of the disease, with a heavy mortality rate among the patients
and resulting in the death of two of the nurses. For some unknown reason there
were but a few cases among the female patients, though close upon 50 per cent, of
the female staff contracted the disease, etc.”

The report of the Visiting Commissioner is not reproduced. The
balance in favour of building and repairs fund account is
,£8,871 iu. 11 d., of which £4,156 10 s. o d. has been lent to the main¬
tenance account—an occurrence we have not noted before in any financial
statement. The balance recorded in favour of maintenance was
£10,740 17 s. 4 d. Cash assets and money due to maintenance was
£6,547 3 s. 7 d. to meet cash payments of £2,831 41. 2 d. and
£3,715 19J. 5 d. towards repaying the sum borrowed from building and
repairs account. The value of stock in hand was £11,203 7 s. 9 d.,
which covers £10,740 17 s. 4d. balance on maintenance account and
£462 ioj. 5//. of the loan from building and repairs account. The
financial position, therefore, would appear to be that maintenance would
have to its credit, after paying its liabilities, stocks to the value of
£10,740 7 s. 4 d. but no cash, and the building and repairs account
a cash credit of ,£8,335 os - 4^-

Portsmouth Borough. —Dr. Devine reports :

“American occupation .—The outstanding event of the year was the conversion
of the institution into an American war hospital. The necessary adjustments,
financial and otherwise, were based on a scheme similar to that under which other
asylums had been handed over to the War Office during the course of the war.
Owing to the fact, however, that an American unit was to take over the Hospital,
it was impossible to utilise the medical, clerical and nursing staff for military
purposes as had been done in other instances. The engineering, laundry, kitchen
and needle-room staff were loaned to the American unit during their occupation,
and those male and female nurses who volunteered were sent with the patients to
the other institutions. Furthermore, as it was impossible to transfer the private

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EPITOME.

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patients to other hospitals, the villas were retained for their accommodation, and
it became necessary to set np an administrative department and nursing staff,
distinct from that of the war hospital, to deal with the portion of the asylum
remaining under the control of the Committee of Visitors. At the request of the
U.S.A. authorities your Medical Superintendent w r as attached to their staff as
Psychiatrist, to treat the mental cases and war neuroses, and to carry out the duties
of a liaison officer. He was commissioned in the R.A.M.C., and served for a short
period at the U.S.A. Base Hospital 117 in France.

“ The officers and staff generally have fully co-operated with me in the administra¬
tion of the institution. The American occupation naturally meant a certain degree
of personal sacrifice on the part of the staff, and it was in a measure due to the
fact that many were willing to submit to personal inconvenience that the scheme
was successfully carried through.”

The accounts reveal an excellent financial position.

West Riding , Yorkshire. —Dr. Shaw Bolton reports that 31.8 per
cent, of the deaths were from tuberculosis.

“The incidence of tuberculosis has increased from 157 in 1916 to 26'2 in 1917,
and to the high figure of 3I'8 in 1918. The obvious explanation of this continued
rise is that the morbidity which was produced by special causes during the year
1917 resulted, in the case of tuberculosis, in effects lasting beyond one year.”

The increased prevalence of tuberculosis during the war mentioned
in so many of the mental hospital reports is clearly indicative that in
the tubercle bacillus there is an enemy only just kept at bay under the
best of circumstances. Open-air treatment, free ventilation, segrega¬
tion of suspected cases and careful attention to the dietary are the only
sound prophylactic measures. There should be also facilities for X-ray
examination of chests, in cases of stupor and others with visceral
anaesthesia and loss of natural reflexes, to assist the early diagnosis of
incipient phthisis. In a few mental hospitals the necessary apparatus
is installed, and it is hoped that those mental hospitals which were con¬
verted to war hospitals will retain a complete installation, and others not
so fortunate in this matter take Steps to acquire one. A lead from the
Board of Control would be helpful.

Those of us who have in mind the epidemics of dysentery which
have occurred at Wakefield will read the following comment with
satisfaction :

“Connected no doubt with the increased nutrition of the patients and with (for
the first time for many years) the employment of artificial heating during the night
throughout the institution during the winter months, a gratifying fall in the
percentage incidence of dysentery to the relatively low figure of 77 has occurred. 1 '

Regarding the out-patient department Dr. Shaw Bolton reports :

“The work of the Out-Patient Department has again begun to increase, and the
number of new cases, 65, is nearly up to the pre-war standard. One hundred and
fifty-seven cases are at the present time under treatment.”

In quite a humble way every mental hospital could do useful work
in this direction. Even if objections are raised to seeing new cases as
out-patients, nothing can be urged against keeping in touch with patients
who have been discharged, helping, advising and encouraging them
from time to time, and treating early symptoms indicative of the approach
of a relapse. Such work would be of great educative value to young
medical officers, and as regards prevention it would pay the country to
refund the out-of-pocket expenses incurred by discharged patients on

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Of those who recovered no less than 69 '2 per cent, suffered from
insanity for the first time of less than three months’ duration on
admission.

The balance in hand on the maintenance account increased from
^6,997 2 s. id. to ,£11,590 13^. 4 d .—a very creditable record. The
balance in favour of the farm and garden is ,£2,787 8 s. 11 d. and the
average cost per head per week is 14J. 7 d. The authorised accom¬
modation is 982—a convenient size for economical administration.

Worcester County and City , Powick .—During the year Dr. Braine-
Hartnell has had a strenuous time, but managed to keep things going
in spite of exceptional adversity. The Commissioner reports :

“The female staff is much below the normal in number, and great difficulty is
experienced in obtaining candidates for the posts. The clerk, the storekeeper, the
stores clerk and the stores porter are also away on military duties, their places being
taken by a girl clerk and a patient only, with the baker to act as porter. This has
necessitated Dr. Braine-Hartnell spending a very considerable portion of his time
in clerical duties, and has prevented him from undertaking practically any medical
work, or ward supervision. He must have been through a most arduous and
anxious time, but I hope that the near future will see the return of his old staff and
the end of most of his difficulties.”

Out of 373 deaths 174 succumbed to phthisis or 46 percent. Dr.
Braine-Hartnell states that:

“ Phthisis is very prevalent, and was responsible for more than half the number
of deaths. I attribute this to overcrowding in the early days of the war and to the
reduction in the dietary. The seeds were then sown and we are now reaping the
harvest. Since the dietary has been increased the health and weight of the
patients have improved.”

As Dr. Wolseley-Lewis says, a not unimportant part in the genesis
of tuberculosis is played by influenza, which visited this mental
hospital, with a fatal result on thirteen cases.

The Commissioner also has something to say in this matter:

“ Phthisis I regret to say has been very prevalent throughout the Institution, and
on my round I noted that fifteen male and fifteen females patients were being
treated in bed for this disease. These cases were spread all over the building, as
is shown by the fact that they were being treated in no less than seven wards on
the female and five on the male side. It appears to me that this must tend towards
the further spread of the disease, and I hope it may be possible in future to con¬
gregate them in one ward on each side, the females being placed in the ward in
the annexe to which the large verandah is attached, and to keep them separated, to as
great an extent as possible, from the other patients. I understand that owing to
shortage of staff it is not possible to utilise the isolation hospital for this purpose
at present.”

This is more easily said than done and Dr. Braine-Hartnell cannot
be unaware of the importance of segregating tubercular patients as far as
possible.

These patients are not only tubercular but insane, and it not infre¬
quently happens that their treatment in an infirmary is out of the
question, and in some cases they would have to be strapped to the bed
to treat them on verandahs. Judging from the number dying, the
infirmaries of this hospital must already swarm with phthisical patients.
There is only one way of dealing with such cases, and that is segregation in
a specially designed ward or building quite separate from any other infirm.

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or sick cases. Few mental hospitals have this really suitable accom¬
modation. It should be additional accommodation so as to remove
any temptation to use it for ordinary cases. Until the various local
authorities take the necessary steps to provide it, anything like complete
and effective isolation of phthisis will as a rule be quite impossible.

The balance in hand of j£i,44 $ ior. 9 d. on maintenance at the
end of the year became a debt of ^1,086 os. 9 d. The farm made
^2,194 13J. 5 d. The balance-sheet of liabilities and assets shows a
balance of ^14,727 ij. 7 d., in favour of maintenance, of which
^1,237 iij. 10 d. is value of stock in hand. The average weekly cost
per head is 155. ioid.

Part IV.—Notes and News.

MEDICO-PSYCHOLOGICAL ASSOCIATION OF GREAT BRITAIN

AND IRELAND.

The Quarterly Meeting of the Association was held at the House of the
Royal Society of Medicine, London, on Thursday, May^oth, 1920, Dr. Bedford
Pierce (President) in the chair.

Members present: Dr. Bedford Pierce (President), Major R. Worth (General
Secretary), Sir J. Crichton-Browne, Sir David Ferrier, Sir George Savage, Sir R.
Armstrong-Jones, Sir F. W. Mott, Drs. H. M. Baker, F. Beech, D. Bowers, A.
Helen Boyle, J. Carswell, J. Chambers, R. H. Cole, A. W. Daniel, W. R. Dawson,
H. Devine, L F. Dixon, C. F. Fothergill, S. J. Gilfillan, T. C. Graves, T. A.
Greene, H. E. Haynes, H. W. Hills, R. R. Leeper, J. R. Lord, J. Macarthur, E.
Mapother, W. F. Menzies, D. Nicholson, M. J. Nolan, H. J. Norman, D. Ogilvy,
R. W. Prentice, N. Raw, G. M. Robertson, D. Ross, J. Scott, J. N. Sergeant, B. H.
Shaw, E. B. Sherlock, G. E. Shuttleworth, R. Percy Smith, F. G. Soutar, R. H.
Steen, J. B. Spence, J. Stewart, R. C. Stewart, R. Stilwell, D. G. Thomson, C. M.
Tuke, J. R. Whitwell, H. Wolseley-Lewis.

Members present at the Council Meeting, held at the Medical Society’s Rooms,
No. 11, Chandos St., W. 1: Dr. Bedford Pierce (President), Major R. Worth,
(General Secretary), Lieut.-Colonels W. R. Dawson, J. R. Lord, D. G. Thomson,
Drs. D. Bowers, Helen Boyle, J. Chambers, R. H. Cole, A. W. Daniel, R. R.
Leeper, W. F. Menzies, A. Miller, M. J. Nolan, J. Noel Sergeant, G. E. Shuttle-
worth, R. H. Steen, H. Wolseley-Lewis.

The minutes of the last meeting, having already been published in the Journal,
were taken as read and were duly confirmed.

The Hon. Secretary (Major R. Worth) announced that letters of regret for
absence had been received from Cols. Keay, A. H. Kidd, and Drs. Douglas McRae,
Patrick Steele, J. P. Westrup, John Mills, J. P. Park-Inglis, T. C. McKenzie,
C. C. Easterbrook, T. S. Adair, R. Eager, and J. McClintock.

Matters Arising from the Council Meeting.

The President said the Registrar had reported greatly increased numbers of
entrants for both the preliminary and final examinations for the proficiency certificate.

The President referred to the Asylum Workers’ Benevolent Fund, which had
been handed over to the Association, with the request that the Council would
distribute it in accordance with the terms of the benefaction. Applications for
assistance from it should be addressed to the General Secretary of this Association,
who would then send to be filled up the necessary form. A notice in regard to
this would appear in the next issue of the Journal.

The President announced that the Sub-committee on Post-Graduate Teaching

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and the Diploma in Psychiatry had been formed, consisting of Colonel Lord, Dr.
Chambers, Sir F. W. Mott, Dr. Orr, Colonel Rows, Dr. C. H. Bond and Dr. Percy
Smith. Colonel Lord had kindly consented to act as convener of the first meeting
of the Sub-committee.

The appointment of this sub-committee was then confirmed.

The President then said that the Association had suggested his name to the
Minister of Health as a member of the General Nursing Council for England,
and he had had the honour of being elected. Meetings had been held, but, as yet,
no business affecting mental nurses specially had been transacted. That aspect
was likely to come up shortly, however, and the Council and the Education
Committee had given some consideration to the question. It was well known
that the Act provided that existing nurses should be registered, on terms. Briefly
stated, those terms were, that the person should be of the required age, should
provide evidence satisfactory to the Council as to good character, should have
adequate knowlege, and have had experience, and should have worked under
conditions which were approved by the Council. He gathered that a large number
of nurses whom the Association did not regard as well qualified would be placed on
the Register, and they had expressly asked that those nurses who had received
the Association’s Certificate should have some distinctive mark against the entries
of their names on the Register. It remained to be seen how far these efforts would
be successful.

Regarding the Handbook Committee, it had had a number of long meetings,
and the initial stages in the production of the revised volume had been dealt with.
The work had been allotted to a number of people who had kindly offered to
contribute articles, and it was hoped that the new Handbook would be a distinct
improvement upon the old one. The general policy of the Handbook Committee
had been to maintain the standard, and not to raise it unduly. It was hoped,
however, that it would be cast in simpler language and would prove more useful
to the nurses than the present one.

The following were elected Members of the Association :

Bowen, Tudor David John, M.R.C.S., L.R.C.P., Assistant Medical Officer,
Napsbury Mental Hospital, Napsbury, St. Albans.

Proposed by Drs. L. Rolleston, H. J. Roberts and R. Worth.

O'Neill, Arthur, M.R.C.S., L.R.C.P., Assistant Medical Officer, Napsbury
Mental Hospital, Napsbury, St. Albans.

Proposed by Drs. L. Rolleston, H. J. Roberts and R. Worth.

Westwater, John Sinclair, M.B., Ch.B.Edin., Assistant Medical Officer,
Napsbury Mental Hospital, Napsbury, St. Albans.

Proposed by Drs. L. Rolleston, H. J. Roberts and R. Worth.

Read, Walter Wolfe, M.R.C.S., L.R.C.P., M.D.Brux., Medical Super¬
intendent, Berkshire County Asylum, Moulsford.

Proposed by Drs. A. W. Neill, R. Worth and G. Warwick Smith.

Rickman, John, M.A., M.B., B.Ch.Cantab., Assistant Medical Officer,
Cambridgeshire Mental Hospital, County Mental Hospital, Cambridge.

Proposed by Drs. M. A. Archdale, R. Worth and G. Warwick Smith.

Bryce, William Henderson, M.B., C.M., Medical Superintendent, Kenlaw
House, Colinsburgh, Fife.

Proposed by Drs. R. B. Campbell, G. M. Robertson and John Keay.

Earp, John Rosslyn, M.R.C.S., L.R.C.P., late Assistant Resident Medical
Officer,City of London Hospital; 81, Woodstock Avenue, London, N.W.4.

Proposed by Drs. Bedford Pierce, B. Hart and R. Worth.

Kimber, William Joseph Teil, M.R.C.S.Eng., L.R.C.P.Lond., Senior
Assistant Medical Officer, Herts County Mental Hospital, Hill End, St.
Albans.

Proposed by Drs. A. N. Boycott, J. G. Smith and L. Rolleston.

Thomson, William George, M.A., M.B., Ch.B., D.P.H.Aberdeen, Tempo¬
rary Assistant Medical Officer, County Mental Hospital, Cheddleton, Leek.

Proposed by Drs. W. F. Menzies, W. D. Wilkins and R. Worth.

Birch, W. S., M.R.C.S. Eng., L.R.C.P.Lond., Second Assistant Medical
Officer, City of London Mental Hospital, Dartford; Stone House, Dartford,
Kent.

Proposed by Drs. R. H. Steen, N. Navarra and R. Worth.

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Nix, Sidney, M.D., Senior Assistant Medical Officer, Graylingwell Mental
Hospital, Chichester.

Proposed by Drs. H. A. Kidd, R. H. Steen and G. E. Peachell.

Fox, J. Tylor, M.A., M.D., B.Ch.Cantab., Medical Superintendent, Ling-
field Epileptic Colony; The Homestead, Lingfield, Surrey.

Proposed by Drs. Bedford Pierce, H. J. Mackenzie and R. Worth.

Hamblin-Smith, Maurice, M.A.Cantab., M.D.Durham, Medical Officer,
H.M. Prison, Birmingham.

Proposed by Drs. G. A. Auden, R. Worth and G. Warwick Smith.

Hills, T. W. S., B.C.Cantab., L.S.A., Senior Assistant Medical Officer,
Leavesden Mental Hospital, Kings Langley, Herts.

Proposed by Drs. F. A. Elkins, E. B. Sherlock and J. Farquharson Powell.

Hooper, Reginald Arthur, M.B., B.S.Durham, Assistant Medical Officer,
Netherne Mental Hospital, Coulsdon, Surrey.

Proposed by Drs. P. C. Coombes, L. M. Webber and R. Worth.

Connell, O. G., M.C., L.R.C.P. & S.I., Senior Assistant Medical Officer,
Mental Hospital, Thorpe, Norwich.

Proposed by Drs. D. G. Thomson, R. Worth and G. Warwick Smith.

McAlister, William, M.A., M.B., Ch.B., Assistant Physician, Royal Edin¬
burgh Asylum; West House, Morningside, Edinburgh.

Proposed by Drs. G. M. Robertson, E. M. Johnstone and Henry Yellowlees.

Gordon, George, M.B., Ch.B., Medical Officer, Lord Derby War Hospital;
c/o Holt & Co., 3, Whitehall Place, London, S.W.

Proposed by Drs. J. Rodgers, R. Worth and G. Warwick Smith.

Thomas, Frederic Percival Selwyn, M.B., Ch.B.Viet., Manchester;
Chairman, Neurological Pensions Medical Board, Potteries Area ; Ranelagh,
Chesterton, Newcastle, Staffs.

Proposed by Drs. W. F. Menzies, W. D. Wilkins and R. Worth.

The meeting then partook more of a public character in order to hear Sir James
Crichton-Browne deliver the Maudsley Lecture (see p. 199).

SOUTH-EASTERN DIVISION.

The Spring Meeting of the South-Eastern Division was held by the courtesy
of Drs. H. E. and H. G. L. Haynes at Littleton Hall, Brentwood, Essex, on
Wednesday, May 5th, 1920.

Among those present were—Drs. Archdale, Bower, Edwards, H. E. Haynes,
H. G. L. Haynes, Hughes, Hyslop, Norman, Oliver, and J. Noel Sergeant, Hon.
Divisional Secretary.

Expressions of regret at inability to be present were received from Sir
Marriott Cooke, and Drs. Anthony, Bartlett, Blandford, Bevan-Lewis, Boyle,
Caldecott, Collins, Devine, Gilfillan, Heal, Higson, Johnston, Kidd, Downs,
McRae, Murray, Nolan, Phillips, Price, Raynes, Rows, Shuttleworth, G. H. H.
Smith, G. W. Smith, R. Percy Smith, Thomson, Turner, Walford, Whittington,
Whitwell.

At 1.30 p.m. Dr. H. E. Haynes entertained the members to luncheon. At the
close of lunch Dr. James Stewart proposed a vote of thanks to Dr. H. E. Haynes
for his kindness in so hospitably receiving the Division. Dr. Haynes responded.

The various parts of the house and grounds were then visited and at 3.30 p.m.
the meeting was held.

Dr. H. E. Haynes took the Chair.

The Minutes of the last Meeting were taken as read and confirmed.

Dr. Sergeant was elected Hon. Divisional Secretary and Drs. Bower, Brander,
Craig and Steen Representative Members of the Council for the year 1920-21.

Drs. Gordon Johnston and Tuke were elected to fill vacancies on the Divisional
Committee of Management.

The invitation to hold the Autumn Meeting at the Three Counties Asylum,
Arlesey, Beds, was accepted with thanks, and the date of the meeting was fixed for
Thursday, October 14th, 1920.

Dr. Hyslop then read his paper on “Venous Stasis.” Drs. H. E. Haynes,
Edwards, and Norman took part in the ensuing discussion.

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A hearty vote of thanks to Dr. H. E. Haynes for his kindly hospitality was
proposed by Dr. Bower, seconded by Dr. Edwards, and carried by acclamation.

Mrs. Haynes then entertained the members to tea and so concluded a most
enjoyable meeting.

Subsequently Drs. Bower, Edwards, H. E. Haynes, H. G. L. Haynes, Norman
and Sergeant dined together at the Cafe Monico.

SOUTH-WESTERN DIVISION.

The Spring Meeting of the above Division was held, by the kind invitation
of Dr. Devine, at the Corporation Mental Hospital, Portsmouth, on Friday, April
23rd, 1920.

The following members were present:—Drs. Devine, Erskine, Nelis, Prentice,
Kidd, Stanford Read, Stokes, Williams, and Dr. Bartlett, Hon. Divisional Secretary.

Dr. Devine was voted to the Chair, and extended a cordial welcome to the
visitors—Sir G. Archdall Reid, Drs. Fraser, Inman, Kerr, Waterfield.

There were letters of regret for non-attendance from Drs. Aveline, Mary Martin,
MacBryan, McRae, Grigsby, Peachell, Soutar and Westrup

Dr. Bartlett was appointed Hon. Divisional Secretary.

Drs. MacBryan and Soutar were elected as Representative Members of Council.

Drs. Devine and Stanford Read were elected as Members of the Committee of
Management.

The date of the Autumn Meeting was fixed for October 29th, 1920, the place to
be left in the hands of the Secretary; the date of the next Spring Meeting April
24th, 1921.

Dr. Stanford Read, Physician to Fisherton House, then read his paper,
entitled, “ The Psychopathology of Alcoholism and some so-called Alcoholic
Psychoses.” Dr. Read ably led his hearers to re-consider alcoholism in its long-
accepted relation to the psychoses, and the meeting strongly expressed their
appreciation of his views and most interesting paper, which resulted in a productive
discussion, in which Sir G. Archdall Reid, Drs. Devine, Prentice, Williams,
Erskine, Fraser and Inman participated.

A hearty vote of thanks was accorded to Dr. Devine for his kindness and
hospitality.

NORTHERN AND MIDLAND DIVISION.

The Spring Meeting of the Northern and Midland Division was held at the
kind invitation of Dr. Geddes at the Mental Hospital, Middlesbrough, on
Thursday, April 29th, 1920.

The President, Dr. Bedford Pierce, in the chair.

The following fourteen members were present:

Drs. H. G. Drakc-Brockman, A. J. Eades, J. W. Geddes, H. W. Kershaw,
R. R. Kirwan, H. I. Mackenzie, H. D. MacPhail, G. F. May, Bedford Pierce,
E. S. Simpson, R. C. Stewart, J. B. Tighe, R. C. Walker and T. S. Adair.

Several apologies were received for non-attendance.

The minutes of the last meeting were read and confirmed.

Dr. J. R. Gilmour was unanimously appointed secretary for the ensuing year—
proposed by Dr. Geddes and seconded by Dr. Stewart.

Drs. R. R. Kirwan and T. S. Adair were elected Representative Members of
Council—proposed by Dr. Pierce and seconded by Dr. Geddes.

The kind invitations of Dr. Hunter to hold the Autumn Meeting, 1920, at the
Coppice, Nottingham, on October 21st, and of Dr. Tighe to hold the Spring
Meeting, 1921, at the Gateshead Mental Hospital, Stannington, on April 21st, 1921,
were heartily and cordially accepted on the proposal of Dr. Pierce, seconded by
Dr. Mackenzie.

Dr. Pierce made some reference to the resolution passed at the last meeting of
the Division, and to the future arrangements regarding the Nursing Examination.

Dr. Drake-Brockman then introduced the question of voluntary boarders in
asylums. He thought that it was desirable that public asylums should be allowed

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to take up work in this direction. After considerable discussion the following
resolution was proposed by Dr. Drake-Brockman, seconded by Dr. Stewart, and
carried unanimously:

“ That the members present at this Divisional Meeting desire to draw attention
to the fact that it is not possible to receive patients into public mental hospitals
upon a voluntary basis, and feel that this statutory bar to treatment should be
removed without delay.”

The Secretary was instructed to forward a copy of the resolution to the General
Secretary at once, in order that it might, if possible, be in time for the May
meeting. Various other questions were generally and informally talked about,
such as the size of the Northern and Midland Division and the difficulty of
getting many to attend the meetings, that of getting more members and
encouraging scientific work amongst the newer and younger men in asylums, and
the suggestion that men engaged more particularly in neurological work should
be invited to join.

A very enjoyable meeting terminated with a hearty vote of thanks to Dr. Geddes
and to the Committee of Visitors of the Hospital for their kindness and
hospitality.

IRISH DIVISION.

The Spring Meeting of the Irish Division was held at the Royal College
of Physicians, Kildare Street, Dublin, on April 1st, 1920.

Members present: Lieut.-Col. Dawson, in the chair; Dr. Gavin, Dr. Mills,
Dr. H. R. C. Rutherford, Dr. Leeper (Hon. Sec ).

Letters and apologies for unavoidable absence were read from John M’Colles,
K.C., Dr. Martin, Dr. Nolan.

The minutes of the previous meeting were read and signed, and also of the
special meeting of the Division recently held to consider the Memorandum
regarding Irish Lunacy Legislation.

A ballot for the election of an Hon. Secretary and two Representative Members
of Council was next proceeded with. Dr. Gavin and Dr. Rutherford acted as
scrutineers of the ballot.

The Chairman declared that Dr. Leeper was elected Hon. Secretary, and
Dr. J. O’C. Donelan, Richmond Asylum, and Dr. Martin, Donegal District
Asylum, Letterkenny, were elected Representative Members of Council for the
Irish Division.

Dr. J. O’C. Donelan and Dr. H. R. C. Rutherford were nominated as Examiners
for the Certificate of the Association for the coming year.

Dr. Geoffrey Norman Smyth, Assistant Medical Officer, St. Edmundsbury,
Lucan, having been duly proposed, seconded and balloted for, was elected a
member of the Association.

The following dates were fixed for the meetings of the Division for the ensuing
year:

Summer Meeting, to be arranged for at either Belfast or Mullingar on Thursday,
June 24th, 1920.

Autumn Meeting, Thursday, November 4th, at College of Physicians.

Spring Meeting, Thursday, April 7th, 1921.

Summer Meeting, Thursday, July 7th, 1921.

The meeting considered the position of asylum nurses under the Nurses’
Registration Bill, and noted with regret that no representation in the First
Irish General Nursing Council had been given to asylum officers or nurses, male
or female. The Hon. Secretary was directed to draw up a statement to be
forwarded to the Chief Secretary drawing attention to this serious omission.

The meeting next considered the possible effects on Irish Lunacy Legislation
of the Home Rule Bill now before Parliament, and it was decided that no action
on the part of the Irish Division was desirable at present.

This terminated the proceedings.

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TREATMENT OF INCIPIENT MENTAL DISEASE.

During the last few years evidence has been accumulating that there is a strong
movement of opinion, both within and without the profession, in favour of a
modification of the lunacy law, the main object being to make better provision for
the treatment of incipient or early cases of mental disorder.

The matter was under the consideration of the Medico-Psychological Association
of Great Britain and Ireland before the war, and in 1914 a full report on the status
of psychiatry was issued. The war prevented any steps being taken to translate
the important resolutions then adopted into practice ; but the war itself had the
effect of arousing new interest in the whole subject of mental disorders, and pro¬
duced a new attitude on the part of both the public and the medical profession.
The Medico-Psychological Association therefore felt that the ferment of recon¬
struction in the air, particularly as regards questions of health, made it desirable
that its position on this matter should be reviewed and a further report issued
representing the most recent opinion as to how the objects in view could best be
accomplished, so that the Association would be ready to direct and support any
measures of reform that might be proposed. The matter was very carefully con¬
sidered by a special committee, and its report eventually received the unanimous
approval of a general meeting.

In its main features the report is in harmony with views set out from time to time
in this Journal; nor do they differ in principle from the recommendations made by
the Board of Control in its annual reports. In regard to clinics the Board of
Control proposes permissive legislation enabling cases of mental disorder, incipient
in character or of recent origin, to receive treatment in general or special hospitals,
mental institutions, nursing homes, or elsewhere for limited periods—say six
months—without the necessity for certification under the Lunacy Acts, provided
the place is under the supervision of the Board. This is only an enabling pro¬
posal, but the word “ elsewhere " gives it an exceedingly wide scope. The report
of the Medico-Psychological Association advises that the duty of providing and
maintaining clinics for these purposes should be imposed on local authorities ;
evidently some sort of obligation will be necessary if the reforms recommended are
to be widely and generally adopted within a reasonable time. It is interesting to
observe that the cases under consideration are described by the Board of Control
as “incipient in character or of recent origin ” ; presumably these two phrases are
not intended to cover identical cases, and if that presumption be correct it seems
to follow that the cases need not be merely “ of recent origin ”—a phrase which it
would be extremely difficult to define and when defined to apply in practice—but
may be " incipient in character.” This would apparently cover many cases which
run a long course of an ill-defined or undeveloped type and yet remain incipient in
character. Such cases are difficult to deal with at present, and for that reason the
extension of the principle would be valuable. If, however, this is the intention of
the Board, it is difficult to see why the duration of this mode of treatment should
be limited to, “say, six months.” The Medico-Psychological Association does not
specify the period during which the measures proposed should be applicable, nor
does it define what is meant by the term “ early stages.” That would no doubt
have to be dealt with when the matter came before Parliament, but the expressions
used by the Board of Control seem to indicate a way of meeting the difficulty and
allowing sufficient elasticity for practical needs.

Proposals for Reform.

It may be convenient to set out the main conclusions arrived at in the report of
the Medico-Psychological Association:

(1) That no steps be taken at present to obtain a complete revision of the
Lunacy Acts, but to seek to obtain amendments only to those Acts.

(2) That it be made the duty of local authorities, either themselves or by
arrangement with voluntary organisations, to establish and maintain clinics for
the treatment of nervous and mental diseases in their early stages, special provision
being made in the organisation for children.

(3) That these clinics should be housed in special buildings, or in an annexe to a
general hospital, be staffed by a special staff trained for the work, and managed by
a special committee appointed for the purpose, and that the buildings should be
inspected and approved by a Central Government Department.

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(4) That all institutions for the insane should be allowed and encouraged to
admit patients as voluntary boarders under suitable conditions, one of which is the
extension of the notice required to be given by the patient of his desire to leave
the institution to forty-eight hours.

(5) That the Board of Control should have power to allow the reception of
patients suffering from mental disease in its early stages without certification in
approved homes, or as single patients in ordinary houses, in regard to which a
medical practitioner gives a written recommendation stating that suitable treatment
can there be obtained, the fact only of such reception to be intimated to the Board.

Several supplementary recommendations are made for improving the admini¬
stration of the Act, mainly in the interests of the insane.

There can be little doubt that if anything is to be accomplished quickly it is far
wiser in the present pressure upon the time of Parliament to concentrate on the
most urgent amendments rather than to aim at a complete revision of the Lunacy
and Mental Deficiency Acts. A single comprehensive unifying measure was drafted
in 1913, but the Government decided to deal with the mental deficiency question
in a separate measure which, owing to the war, has hardly yet come into full
operation. The Board of Control, in its annual report for 1917, advocates amend¬
ments but not complete revision, nor does the latter process seem necessary in
order to secure those reforms on which there appears to be substantial agreement.

It will be noted that the report of the Medico-Psychological Association proposes
that it should be made the duty of local authorities to provide and maintain clinics.
In this it goes further than the Board of Control, which suggests permissive legis¬
lation only, and the report of the committee to the conference of the visiting
committees of the asylums in England and Wales, held in the Guildhall, London,
in February, 1919. This conference considered that the establishment of special
mental hospitals should be encouraged. There is much to be said in favour of
imposing action by local authorities as a duty. For the success of the plan no
half-hearted approach will be sufficient; it is necessary that it should be familiar
and accessible to everyone if it is to establish itself without prejudice as a recog¬
nised method; for this we have the precedent of the duties imposed on local
authorities by the Mental Deficiency Act, and no doubt provisions will have to be
made in regard to financial assistance to local authorities by the Treasury similar
to those made in that Act. Where such a clinic is established in a special annexe
connected with a general hospital.it is contemplated that the local authority should
come to some arrangement with the hospital board in regard to the cost, etc.
There are precedents for such a course, and it is felt that if hospitals are to be
induced to organise clinics on these lines, which both for educational, scientific,
and practical reasons is so desirable, such financial assistance will be necessary.

In regard to these clinics it has been felt, not only by the Medico-Psychological
Association but also by the Guildhall Committee, that they should as far as possible
be detached in the public mind from all association with the Board of Control. It
is apparently felt that that body is so closely identified with that aspect of the
matter which has to do with restraint of the liberty of the patient, with safeguards
against dangerous patients, and with the protection of the hopelessly confirmed
insane, that the mere fact of the supervision of the proposed clinics being in its
hands would tend to give them a character which would make them distasteful to
those for whose benefit they are devised. Obviously they would properly come
within the purview of the Ministry of Health, and as the Board of Control will, no
doubt, before long be transferred to that Ministry there will be ample facility for
proper co-ordination. It is for the same reason that stress is laid on the view that
these clinics should be housed in special buildings, and be supervised by a com¬
mittee distinct in name from the Asylums or Mental Deficient Committee. Only
as regards private patients does it seem necessary to adhere for practical reasons
to the body administering the Lunacy Acts, as the prohibition for the improper
reception of patients is in their hands, and they must therefore be entrusted with
the administration of any relaxation of that prohibition.

The Voluntary Boarder System.

In one important respect the Board of Control has gone further than the Medico-
Psychological Association. It is prepared to have the principle of the voluntary-
boarder extended not only to all the various classes of institution, but also made

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applicable to patients under single care in private houses. A proposal to this effect
was put forward by Dr. Weatherley in his book A Plea for the Insane, which has
been reviewed in these columns. Such a provision, coupled with the proposed
provision for private patients in approved homes or as single cases in homes not
so approved, would go far to cover all reasonable requirements for suitable treat¬
ment of the early nervous and mental disorders in this class of the community.
Where detention is necessary recourse can be had to the private asylums, whether
as a voluntary boarder or as a certified case. Where the asylum treatment is not
necessary detention would be allowed, either under certificates or as a voluntary
boarder, or as a single patient, and where neither of these arrangements are
necessary or desired, the patient could be dealt with without any formality beyond
the intimation to the Board that a patient was being received in a certain house
and evidence that suitable treatment can there be obtained. It is proposed that
the provisions applying to approved homes shall be applicable also to licensed
houses and other institutions for the insane. It will be clear that with such wide
and varied liberty of choice it is extremely unlikely that a medical man would
recommend a patient to avail himself of any place of treatment which did not
adopt one or other of these provisions, and there would be no necessary hardship
to the patient in so doing, and consequently no reputable person proposing to
receive patients in his house would attempt to evade such provisions. Thus would
be eliminated one of the principal difficulties of members of the profession in regard
to private patients—that it is not open to them to advise the treatment which they
consider best for the health of their patient without the risk of running counter to
the law.

The interest taken in the matter was shown a short time ago by the publication
of a manifesto on psychiatric clinics for studying the treatment of mental disorders
in the early stage, bearing the signatures of Sir Clifford Allbutt, Sir George Savage,
Sir Frederick Mott, Dr. Edwin Goodall, Medical Superintendent of Cardiff Mental
Hospital, and others more or less directly concerned with the treatment of such
disorders. It was therein stated that the necessity of carrying out the reforms out¬
lined had been repeatedly urged in the leading organs of the medical profession,
and that the policy recommended would be generally endorsed. The main features
of the policy indicated are the provision of clinics in large centres of population,
but especially in connection with the general hospitals and schools of medicine. It
is proposed to extend the system of voluntary admission which now exists in respect
of licensed houses and registered hospitals for the insane, so that patients, whether
of the private or rate-aided class, may place themselves in county borough mental
hospitals. It is proposed, further, that the private patient class should be received
without certification, but with the cognizance of the Board of Control, in homes
privately owned or supported wholly or partly by voluntary contributions, or in
existing public and private mental hospitals (licensed houses). The two methods
of admission to county borough mental hospitals or into private hospitals are
given as alternatives, but we presume that both are desired.

The establishment of clinics in psychiatry, with in- and out-patient departments
as a part of the general hospital system, is regarded as the most important of the
above proposals, since it is by this method that the never-ending extensions of
existing asylums may best be avoided. In such clinics patients would be received
without reception orders or certificates, and subject to the minimum of official
supervision. They might be treated under these conditions for six months, and in
them students and the future holders of posts in mental hospitals should be taught,
all available means of research being provided. It was with this idea that the late Dr.
Henry Maudsley eleven years ago made his munificent gift, ultimately amounting
to .£40,000, which, after much delay, resulted in the erection of the Maudsley
Neurological Hospital at Denmark Hill.

Civil and Military Cases.

The manifesto calls attention to the arrangements the army authorities made
for mentally disordered soldiers during the war; they were sent into military
mental hospitals without any orders or certificates, and were only removed to
asylums when, after nine months, they were deemed incurable. Large numbers of
men were received in very early phases of the disease, and the advantages were
very great. The suggestion is then made that “ if these men could be treated thus

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whilst in khaki, they could and should be similarly treated as civilians, and under
far better medical conditions than in asylums." This may be so, but it should not
be too readily assumed. Disciplinary powers over the man in khaki are great, and
render the need for control by certification in his case superfluous. Whether
civilian patients can be equally successfully managed will depend on the extent to
which the public will be content to permit a reasonable amount of similar control
being exercised in the patients’ interest without regularised powers. There may
be grounds for hoping that the experience of educational influences during the war
may have rendered such an attitude on the part of the public general; but it cannot
be denied that there is still an important section of it to whom a meticulous care
for the liberty of the individual overshadows the provision for his well-being as a
sick person.

There is, however, another difference between the civil and the military case.
The soldier who is unfit to continue his duties owing to ill-health has no induce¬
ment to go on working, and comes automatically under medical direction. The
civilian may continue his work when really unfit, or retire to his home and take no
steps to secure treatment, or he may refuse to act on his doctor’s advice. He and
his friends must therefore be taught to turn naturally to the clinic for assistance,
and he will judge of the clinic and accept or refuse its help according to the type
of malady which will come in time to be associated with it in the course of actual
experience.

Legislative Aims.

It is understood that the Board of Control has drafted a Bill to carry into effect
the changes in this direction which it has recommended in its reports. Although
officials speak hopefully of the probability of the early passage of the Bill into law,
its terms have not yet been made known, and the prospects of early legislation do
not seem to onlookers very bright.

The results which will be achieved must to a large extent depend on the detailed
provisions and also on the spirit in which they are interpreted. For example, there
are some whose principal object is to save those suffering from acute but transitory
forms of mental disorder from certification by allowing them to be dealt with under
the new provisions ; there are others, on the other hand, who are more anxious to
secure the treatment of cases in an early stage so as to stave off mental break¬
down, and for this purpose they hope to bring under treatment the antecedent
stages which are little regarded by many at present.

It is clear that unless there are very special and extensive facilities, the use of
the clinics for the first group of cases would tend to conflict with their utility for
the second. The clinics will come to be characterised not by the name that is
given to them, but by the cases to the treatment of which they are devoted; care
will have to be exercised if they are not to come to be looked upon as simply an
unofficial type of asylum .—British Medical Journal, April loth, 1920.

EARLY MENTAL TREATMENT AND THE RIGHTS OF THE

SUBJECT.

Sir, —In the speech in which the Right Hon. Dr. Addison introduced the
Health Ministry Bill, he made explicit reference to “ the inadvisability of including
under the Health Ministry many judicial questions which are not in any sense
medical, such as those that concern the rights of the subject, etc.” In face of this
declaration from such a high authority, it would seem a little curious to notice in
the sketch communicated to your issue of April 10th (p. 515) the remark “ that the
Lunacy Board of Control will no doubt before long be transferred to that Ministry.”
In a preceding sentence the function of that Board is stated as “ having to do with
restraint of the liberty of the patient, with safeguards, etc., and with the protection
of the hopelessly confirmed insane.”

If so transferred, the Board will doubtless have to leave behind it at the Home
Office a large proportion of its duties, for its legal half, at any rate, is intimately
concerned with the rights of the subject, and must consequently (in accord with the
dictum of the Health Minister) be excluded from the purview of his department.

In a memorial presented in July, 1914, to the Local Government Board, and

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supported by half the House of Commons, it was expressly urged that to promote
the recovery of early uncertifiable mental cases it was both inexpedient and
inappropriate that the recuperative hostels or sanatoriums designed for them
should have any connection with the Lunacy Board. The Lunacy Act, 1890,
confers on the Commissioners no jurisdiction over any but the certified—that is, the
incarcerated—and the protection of the helpless (if properly attended to) will give
abundant scope for their energies. It is a sacred trust, involving serious
responsibility.

In the communication of April 10th it is noted that the Lunacy Board desires
" permissive legislation enabling early mental cases to receive treatment for six
months in general or special hospitals or homes without the necessity for certifica¬
tion.” I fail to see where any need for legislation to this end arises. General or
special hospitals or borough hostels can, under the present law, receive and treat
uncertifiable cases at any time, and for any length of time, where no detention is
intended. That is the crux. A patient under the Lunacy Act, S. 74, can only be
justifiably detained if he is proved to be “ dangerous and unfit to be at large.” It
is somewhat difficult, on p. 516, to disentangle the meaning of one or two sentences
dealing with the “ detention of patients as voluntary boarders ”—apparently a
contradiction in terms.

It is, no doubt, a very convenient arrangement for the proprietors of mental
homes to have patients consigned to them for detention on the sole recom¬
mendation of one doctor (p. 515) without any judicial investigation or appeal.
But the ordinary outlook of the public (as the said article sagely comments) has
also to be reckoned with, displaying as it sometimes does " a meticulous care for
the liberty of the individual.” As an instance, recall the defeat of the “ Mental
Treatment Bill,” proposed by the Lunacy Board in 1915.

In devising expedients to evade certification (on the plea of evading “stigma”)
it is overlooked that the legal procedure of certification constitutes the main
bulwark against false imprisonment, and it is highly dangerous to tamper with
such safeguards. Better the risk of an evanescent stigma than the peril of a
lifelong submersion in helpless misery. It is not the safeguarding procedure of
certification that stigmatises, but the degrading element entailed in detention,
coupled with unnecessary indignity, and the loss of all personal and civil rights.

The one hope of an effective check to the constant increase of insanity is the
natural and reasonable provision of untainted homes (kept carefully apart from any
link with lunacy) which shall afford hope, encouragement, and freedom from appre¬
hension, with bodily care and attractive surroundings, appropriate to the restora¬
tion of those highest faculties often temporarily unhinged from quite natural and
sufficient causes. Such is the path of common sense. It is a pity that legislation
should be invoked to destroy the usefulness of these health-giving methods.
Mental homes for uncertifiable cases, free from detention, should immediately be
started by the Health Ministry under suitable local committees, on a purely
hospital footing. Patients would be controlled during their stay by the rules of
the place, but be free to leave on giving a specified notice.

Ex-service men cannot be said to be specially enamoured of the so much
admired regimen of military mental hospitals. Cases of acute transient mania—
for example, influenza, puerperal, etc.—ought to be treated in hospitals as delirious
cases.

Money spent on half-way houses to asylums will be simply thrown away;
whereas mental sanatoriums as above described would prove not only an immense
boon to the community and a benefit to doctors, but by their adaptation to the
needs of early cases would intercept them on the downward track, and tend
eventually to a material reduction in our present huge and unproductive asylum
expenditure.

I am, etc.,

S. E. White, M.B., B.Sc.

London, W.,

April ljth.

British Medical Journal, May 15th, 1920.

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CRIME AND MADNESS: MODERN VIEWS OF RESPONSIBILITY (>)..

From a Legal Correspondent.

It was hoped that when the Court of Criminal Appeal was established some
twelve years ago, the test of responsibility in criminal cases would be examined in the
light of modern knowledge, and the outstanding difference between the legal and
the medical view would come to an end, by a legal decision which would remove a
blot from our criminal law and abolish a rule almost universally condemned by
experts. That was possible without legislation. The tests formulated in Mac-
naghten’s case were answers, which the judges were not bound to give and to which
the House of Lords need not conform, to questions framed in hypothetical language.
They were really only obiter dicta, though often repeated. That hope has not
been realised; its fulfilment is now indefinitely postponed. In the judgment
which The Times lately reported in the appeal in Rex v. Holt, the Court held itself
bound by the answers of the judges in Macnaghten's case. “The tests in R. v-
Macnaghten must be observed.’’ Those tests, based on knowledge of the moral
character of conduct, are condemned by almost all doctors. Those best qualified
to speak are most decided in their objections to them; and the opposition is
strengthened by experience. The late Dr. Maudsley declared the almost universal
opinion of his profession when he described the legal rules on the subject of
responsibility as " unphilosophical in theory and discredited on all hands by
practical experience of insanity.” It “ goes out of its way gratuitously to lay down
as sound law exploded psychological dogma which is not law at all, but false
doctrine.” “ Had the Macnaghten dictum been rigidly insisted on,” says another
eminent medical authority, “it would have been the means of hanging more than
half the women who are now in Broadmoor as criminal lunatics, for the murder of
their children.”

The formula may have embodied the medical knowledge of eighty years ago; it
is in flat opposition to present teaching. The majority of lawyers are no less
critical of these tests. Some judges evade them. Some put to the jury an
alternative test; the judge who tried Holt asked the jury to say whether he was
subject to an uncontrollable impulse. Sir James Stephen, in a careful examination
of the questions, criticised them as unsatisfactory. Sir William Markby rejected
them. One lawyer declared that the answers of the judges “ really contain almost
every form of fallacy or omission.” Lord de Villiers, a great jurist, refused to
follow the ruling of the judges in 1843, because “it practically treats the existence
or otherwise of a specific disease of the mind as a question of law to be decided by
the judges, instead of treating it as a question of fact to be decided by a jury.” A
committee of the New York Bar Association which examined the subject in 1911
condemned the English test; it was, they said, “formulated by judges ignorant of
psychology.”

The majority of foreign codes proceed upon different lines. Thus the German
criminal code, appreciating the importance of the element of will, says that “an
act is not punishable when the person at the time of doing it was in a state of
unconsciousness or disease of mind by which a free determination of the will was
excluded.” The Italian code, like the German code, lays stress on infirmity of
the will. “ A person is not punishable for an act if at the time of committing it he
was in such a state of mental weakness as to deprive him of knowledge of what he
was doing or of freedom of will in regard to it.”

No foreign state, in the many recent new codes of criminal law, has adopted our
test; and even in the American Union, where the English Criminal Law is the
common law, the tendency has been to break away from a rule obviously at variance
with medical science.

We lay less stress on these dicta than on the teaching of psychology, which has
made enormous advances since 1843. The judges who formulated the answers
were little conversant with mental science, and even if they had studied it they
would in all probability have received little assistance as to one part of it, and that
the most relevant to the inquiry into accusability. The mechanism of the will, its
defects and diseases, were then little investigated. It was left to Bain, Wundt, and
many later investigators to examine its pathology and to describe in detail the
infatuation, fascination, irresistible impulses, due in the first instance to the undue

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or morbid persistency in the mind of certain ideas. “ A certain object has by some
means gained possession of us, we are unable to dismiss; where by persisting in
the view, and excluding other things, it may at last find its way into execution.”
Such works as Ribot’s Les Maladies de la Volonte, Maudsley's IV'/// in its
Pathological Relations, Bain’s Emotions and the Will, not to speak of the
special works of "alienists,” enable one to view the problem in a manner not
possible in 1843, and warn us not to express in terms of knowledge what is often a
problem of will-power, or to ignore the many instances of enervation or annihilation
of volition. Ram a crowbar between the spokes of the wheels of a motor and then
say to the chaffeur, " Full speed ahead ” ; knockoff the pinions of a wheel and then
expect the corresponding wheel to revolve—these are no greater absurdities than to
hold as responsible men who see the evil to which with a sort of demoniac force
they are impelled ; slaves of an overmastering idea, powerless to resist that which
they know to be wrong. “ O wretched man that I am,” each one of them might
say with the Apostle. “ What 1 hate that I do ... . the good that I would I do
not; but the evil that I would not, that I do.” Pursued by invisible internal Furies
more terrible than the dread Erinyes that tracked Orestes stained with his mother's
blood, they merit pity rather than reprobation.”

It will be said in defence of the present rule that the Home Secretary will see
that no injustice is done ; that is to say, he administers a more rational law than
that expounded by the Courts—a plea which is really the strongest condemnation
of the latter. It may be added, “ Granted that the present tests are imperfect, what
would you substitute P ” A question, it must be admitted, hard to answer. But
even if no perfect substitute can be suggested, it would be a real service to get rid
of false tests. It may well be that with our present knowledge and with the infinite
variety of symptoms and shades of insanity, no one perfect definition can be
framed. It may be advisable to leave the matter very much at large. The many
attempts to compress into one brief formula a universal test have not been very
successful. It may be best to use very general language as does the French
criminal code : “ There can be no crime nor offence if the accused was in a state
of madness at the time.”

These observations would not be made if the writer had not seen his way to a
practical suggestion. Two courses are open. Under the Court of Criminal Appeal
Act an appeal lies to the House of Lords if the Attorney-General certifies that the
case involves a point of law of exceptional public importance, and that it is
desirable in the public interest that a further appeal should be brought. Or, alter¬
native course, a committee of a few lawyers and doctors might investigate the
subject. The objection to the latter course is that it would open a wide range of
questions closely connected with that here discussed ; for example, the question of
limited criminal responsibility which now forces itself upon criminologists. A full
discussion would involve a consideration of the tests of insanity in civil cases—
for instance, as to capacity to contract or to make a will. Here, too, legal science
is out of touch with medical. Indeed, there may have been retrogression. The
principle enunciated by the Judicial Committee through Lord Brougham in Waring
•v. Waring probably better accords with the principle of the unity of pyschic life than
that subsequently iaid down in Banks t’. Goodfellows.

The advantage of the first course here suggested is that the discussion would be
confined to the narrow manageable issue "Yes” or “No.” Are the tests in
Macnaghten's case sound? The Law Lords need not, indeed could not properly,
travel outside this issue. There is an additional reason in favour of this course in
the fact that they have lately had before them, in the appeal in Rex v. Beard, a
closely related subject. The present Lord Chancellor has already in more than
one field shown the courage and ability to grapple with difficult questions, and the
probability is that a discussion in the House of Lords would clarify the subject and
might efface from English law one point in which it is conspicuously behind most
foreign systems of criminal law.

(') The Times , April 13th, 1920.

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PARLIAMENTARY NEWS.

March 25 th : Sanatoriums for uncertifiable mental cases. —Sir A. Shirley
Benn asked the Pensions Minister if he would state how many sanatoriums were
provided by his department for the benefit of uncertifiable border-line cases of loss
of mental balance occurring among ex-soldiers as distinguished from neurasthenics
of a pseudo-paralytic type, where they were situated, what accommodation they
furnished, and were facilities afforded for interesting occupations for the purpose
of promoting an early return to the conditions of industrial life.—Sir J. Craig
replied : Eighteen institutions, providing 2,046 beds, have been set up by the
Ministry to deal with the cases described. They are situated at Edinburgh,
Shotley Bridge, Leeds (2), Altrincham, Woolton, Stockport, Leicester, Maidenhead,
Bath, Exeter, Orpington, Tooting, Denmark Hill, Roehampton, Chepstow,
Craigend, and Leopardstown. Further institutions are in course of preparation.
Occupational training has been provided at the majority of these homes, and at the
remainder is being instituted as rapidly as possible. Accommodation in the
treatment and training centres will also be available for the convalescent cases
which still require treatment and training. There arc, in addition, clinics at
Lancaster Gate, Manchester and elsewhere where out-patient treatment is given
for the milder type of neurasthenic, such as the pseudo-paralytic type.

March 31s/: Ex-service men in public asylums. —Major Entwistle asked the
Minister of Health if he would state how many discharged soldiers and sailors were
at present in public asylums ; and if it was intended to provide any other accom¬
modation for these men.—Major Baird: The number is about 4,000. As regards
the second part of the question, so far as I am aware there is no intention to
provide other accommodation for these men, and I am advised that there would
be serious objections to treating these cases in special establishments. The matter
is discussed in the report of the Board of Control for 1917. There is also the
important point that under the present arrangements it is possible in many cases
to transfer the patient to an asylum closer to his relatives, and a large number of
applications for such transfers have been received.

Lieut.-Col. Malone: Are not many of these cases not really very serious, and
likely to return to complete sanity if they were put into more suitable accommoda¬
tion ?—Major Baird : I do not think that follows. I think they are receiving the
best possible treatment likely to lead to their recovery.

April 15th: Cost of lunatic patients. —Mr. Charles Edwards asked the
Minister of Health whether he was aware of the continued increase in the cost of
lunatic patients chargeable to boards of guardians maintained at lunatic asylums
and that the 4s. per head now paid was totally inadequate ; and whether he would
introduce legislation to amend the Local Government Act, 1888, so as to provide
for boards of guardians receiving a much higher sum than the above.—Dr. Addison
replied: I can only repeat that in view of the contemplated legislation for the reform
of the Poor Law this point could not advisedly be dealt with at the present time.

April 2jth : Homes for mental cases. —Major Entwistle asked the Pensions
Minister if he would say how many homes of recovery were under his control, how
many mental cases had passed through, and how many were receiving treatment.—
Mr. Macpherson replied : There are twenty such institutions under the control of
the Ministry, and 2,383 men are at present under treatment. I am making inquiry
with regard to the second part of the question, and will inform my honourable and
gallant friend of the result.

Mental cases at Warrington and Whitchurch. —Major Entwistle asked the
Secretary for War and Air if he would state how many mental cases passed
through Warrington and Whitchurch hospitals; how many mental cases had been
reported to his department since August 4th, 1914; how many had recovered ; how
many died; and the disposition of the remainder.—Mr. Churchill replied:
The number of mental cases which passed through the two hospitals mentioned
were: Warrington, 8,410 up to March 31st, 1920, the date of the latest report;
Whitchurch, 1,862 up to January 2nd, 1920, the date on which the hospital was
closed. The figures asked for in the remainder of the question will not be available
until the medical history of the war is published, which will not be for some two
or three years. The following details, however, are available with regard to the
patients treated in the two hospitals referred to in the question : Warrington
LX VI. 23 §

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(from the date of opening to December 31st, 1919): Number of cases treated,
8,127; discharged to their homes recovered, 3,657; discharged to asylums, 1,026;
transferred to other military mental hospitals or repatriated overseas, 2,433 '< died,
108; remaining in hospital, 903. Whitchurch (from date of opening to October
31st, 1919) : Number of cases treated, 1,862 ; discharged to their homes recovered,
1,102; discharged to asylums, 446 ; died, 33 ; remaining in hospital, 281.

April 28th: Shell-shock .—Lord Southborough moved that inquiry should be
made either by a select committee of this House or by departmental committee into
the expert knowledge derived by the Army medical authorities and the medical
professions with the object of recording for use in time to come the experiences of
the war, and advising whether, by military education or otherwise, some scientific
method of dealing with such cases could not be devised. He remarked that when
first the public became acquainted with some of the terrible effects of shell-shock
they were advised that it was a war phenomenon ; but whatever might have been
the diagnosis at the beginning of the war, there was now a fairly general consensus
of opinion in this country, in France and in America that shell-shock cases were
examples of varying types of hysteria and traumatic neurosis, common and well
known in civil life, well understood by medical practitioners, and frequently met
with in railway and other accidents. Our Royal Army medical authorities, in
common with the French, had fully realised the gravity of the disease, and
appreciated that if one understeod hysteria, one was well on the road to understand
shell-shock. Hysteria was a very serious and dangerous malady, and not only did
it present itself in various forms, but it was in a sense contagious. If shell-shock
were hysteria, it should be amenable to the same therapeutic measures both for
prevention and cure. There was plainly all excuse for surprise at the rapid
development of the disease, as it was found that shell-shock or hysteria was not
confined to the untrained soldier alone. It was common with seasoned soldiers
marked out for bravery. What was the meaning of this? The nervous system
broke down under the strain of wear and tear. He believed that the health of a
large number of men who were now doing nothing might be greatly improved by
an organisation designed to give them a little work. In quasi-mental cases he
could imagine no more miserable fate than for a patient to remain in absolute
idleness. Were these men to be kept in their homes permanently, and was it
desirable that various classes of the disorder should be mingled together ? A com¬
mittee of inquiry should have the opportunity of advising upon, collating and
recording the most improved methods of treatment resulting from the experience of
the war. With regard to cases of dereliction of duty followed by court-martial,
and in some instances by the penalty of death, the committee would do well to
examine secretly the evidence given in these cases and consider whether any other
course might have been taken with regard to some of these men. If an inquiry
took place he hoped the War Office would keep back the names of the unfortunate
men, even from the committee.

Lord Horne was convinced that a great field of research would be opened up
for any committee that might be established. There was only one point to which
he thought it needful to refer, in order that an unfavourable impression that might
otherwise arise might be to a certain extent removed. If in the early days of the
war there might have been cases in which injustice was done by the infliction of
the extreme penalty, he confidently asserted—and his knowledge of cases that
came up for confirmation enabled him to speak with experience—that if there was
a shadow of doubt, if there was any suspicion that the crime committed might
have been caused by any form of hysteria the result of shell-shock, the sentence
would not be confirmed until the accused had been under observation of the
medical authorities for a time at some of the detention establishments, and given
every opportunity of allowing those in authority to arrive at a decision as to
whether the mental balance had been in any way affected or not. He was much
struck by the suggestion that inquiry might lead to some form of mental exercise
which would enable our soldiers to be trained to endure nerve-trying conditions.
Personally, he thought it extremely probable that some method might be devised
which would lead to that end. He believed that many of those whose mental
balance was upset did not lose their self-control from the shell, but from the general
effect of the extreme tension on a highly organised nervous system. (Cheers.)
Those who were of a more easy-going temperament were less likely to suffer from
shell-shock.

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Viscount Peel, Under Secretary for War, said this was a very important and
painful question, described under the compendious but inaccurate term of shell¬
shock. No doubt there were cases of shell-shock in former wars, but they were not
recognised as such because we had not got the information that we had at
present. He was unable to say whether during the late war cases of injustice
occurred, but immense trouble was taken at courts-martial and in the subsequent
proceedings that no persons should be condemned to death unless for the
gravest and most serious reasons, and unless all these different causes had
been eliminated. Lord Horne, who spoke with authority and experience, had
testified to the great trouble that had been taken in all stages of the procedure
of the court-martial, and of confirmation to see that no man was condemned to death
who was able justifiably to plead shell-shock or some mental damage of that
kind. Where a soldier in his defence or in mitigation of punishment urged a sub¬
stantial plea on mental grounds medical witnesses were called, and the court-martial
was adjourned and a medical board was held. At the adjourned hearing one or
more members of the board were called as witnesses to give evidence as to the
effects observed and the conclusion of the board upon them. A mental specialist
was always included if there was a suggestion of shell-shock or any other kind of
mental or nervous disorder. If there were the slightest grounds for further inquiry,
the Army or General Headquarters ordered a medical board to examine and to
report before any action was taken to confirm the death sentence. No sentence of
death was carried out in any theatre of war unless it was confirmed by the Com-
mander-in-Chief of the Force, who invariably consulted the Judge Advocate-General.
The view of the Government was that great advantages might be obtained by
such an inquiry as was suggested. Many of the nervous and mental conditions
encountered were entirely new to the medical officers. The connection between
the forms of the disease met with during the war and in civil life was very close,
and experience gained during the war might be of great value in other fields.
The War Office were glad to accept the view that a departmental committee should
be appointed.

June 28 th : Ex-Service Men in Pauper Asylums. —Mr. Hurd asked the Prime
Minister whether his attention had been called to a resolution of the National
Council of the Evangelical Free Churches regarding the incarceration of ex-Ser-
vice men in pauper asylums; whether any ex-Service men were so incarcerated ;
and what steps would be taken to secure their treatment in a way commensurate
with their service.—Major Tryon (Parliamentary Secretary to the Ministry of
Pensions) replied : My right honourable friend’s attention had not been called
to the resolution referred to, but I may say that any ex-Service man suffering from
certifiable insanity who is confined in a county or borough asylum is by special
arrangement treated not as a pauper lunatic, but as a Service patient,
if his condition is found to be due to his service in the late war. As a Service
patient he is entitled to all the privileges of a private patient, the entire cost
of his maintenance and treatment and of the special privileges accorded to him
being borne by the Ministry of Pensions. I am satisfied that it would not be in the
interests of the men themselves or of their relatives that they should be treated in
special establishments devoted exclusively to ex-Service cases. I am, however,
taking steps to assure myself that the present arrangements are in all cases work¬
ing satisfactorily and are the best that can be made in the interests of these un¬
fortunate men.

THE FIRST GENERAL NURSING COUNCIL, ENGLAND.

The following persons have been appointed to form the first General Nursing
Council under the Nurses’ Registration Act of 1919:

Appointed by Privy Council. —Lady Hobhouse and Mr. J. C. Priestley, K.C.
Appointed by Board of Education. —The Hon. Mrs. Eustace Hills and Miss
Batty Tuke, Bedford College.

Appointed by Minister of Health.— The Rev. G. B. Cronshaw, Radcliffe Infirmary,
Oxford; Dr. E. W. Goodall, Dr. A. Bostock Hill, Dr. Bedford Pierce, and Sir
T. Jenner Verrall, M.D.

Nurses Appointed by Minister of Health. —Miss A. Cattell, private practice ; Mr.
T. Christian, nurse, Banstead Lunatic Asylum ; Miss A. Coulton, matron, Shadwell

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Children’s Hospital; Miss R. Cox-Davies, R.R.C., matron, Royal Free Hospital ;
Miss A. Dowbiggin, C.B.E., R.R.C., matron, Edmonton Poor Law Infirmary ; Mrs.
E. G. B. Fenwick, formerly matron, St. Bartholomew’s Hospital; Miss A. Lloyd-
Still, C.B.E., R.R.C., matron, St. Thomas’s Hospital; Miss M. MacCullum, Pro¬
fessional Union of Trained Nurses; Miss I. Macdonald, Royal British Nursing
Association ; Miss A. M. Peterkin, general superintendent, Queen Victoria Jubilee
Nurses; Miss E. Smith, Welsh superintendent, Queen Victoria’s Jubilee Institute
for Nurses; Miss M. E. Sparshott, C.B.E., R.R.C., matron, Royal Infirmary,
Manchester ; Miss E. C. Swiss, health visitor for Willesden; Miss S. E. Villiers,
matron, Stockwell Fever Hospital; Miss C. Worsley, matron, Liverpool Children’s
Hospital; Miss C. S. Yapp, matron, Ashton-under-Lyne Poor Law Infirmary.

Mr. Priestley has been appointed Chairman of the Council.

NURSES REGISTRATION (SCOTLAND) ACT, 1919.

9 & 10 Geo. 5, Ch. 95. 2 3rd December 1919.

(See page 190 for English Act.)

1. —(1) For the purposes of this Act, there shall be established a General
Nursing Council for Scotland (in this Act referred to as “the Council”), which
shall be a body corporate by that name with perpetual succession and a common
seal with power to acquire, hold and dispose of land. The Council may sue and
be sued by that name, and service on the Council of all legal processes and notices
may be effected by service on their registrar.

(2) The Council shall be constituted in accordance with the provisions con¬
tained in the Schedule to this Act.

(3) Any document purporting to be sealed with the seal of the Council or to
be signed in the name of the Council by their registrar or any person authorised
by the Council to act in that behalf shall be receivable in evidence of the par¬
ticulars stated in that document.

2. —(1) It shall be the duty of the Council to form and keep a register of nurses
for the sick (in this Act referred to as “the register”) subject to and in accordance
with the provisions of this Act.

(2) The register shall consist of the following parts:—(a) a general part
containing the names of all nurses who satisfy the conditions of admission to
that part of the register: (A) a supplementary part containing the names of male
nurses: ( c ) a supplementary part containing the names of nurses trained in the
nursing and care of persons suffering from mental diseases: (d) a supplementary
part containing the names of nurses trained in the nursing of sick children:
(e) any other prescribed part.

(3) A certificate under the seal of the Council stating that any person is,
or was at any date, or is not, or was not at any date, duly registered under this
Act shall be conclusive evidence in all courts of law of the fact stated in the
certificate.

3. —(1) The Council shall make rules for the following purposes:—(0) for
regulating the formation, maintenance and publication of the register; (6) for
regulating the issue of certificates and the conditions of admission to the register;
(c) for regulating the conduct of any examinations which may be prescribed as a
condition of admission to the register, and any matters ancillary to or connected
with any such examinations; (d) for prescribing the causes for which, the con¬
ditions under which, and the manner in which nurses may be removed from the
register, the cancellation of certificates of nurses removed from the register, the
procedure for the restoration to the register of nurses who have been removed there¬
from, and the fee to be payable on such restoration ; (e) for regulating the summoning
of meetings of the Council and the proceedings (including quorum) of the

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Council; (/) for enabling the Council to constitute committees and for authorising
the delegation to committees of any of the powers of the Council, and for
regulating the proceedings (including quorum) of committees ; and (g) generally for
making provision with respect to any matters with respect to which the Council
think that provision should be made for the purpose of carrying this Act into
effect (including provision with respect to the uniform or badge which may
be worn by nurses registered under this Act), and for prescribing anything which
under this Act is to be prescribed.

(2) Rules under this section shall contain provisions— (a) requiring as a con¬
dition of the admission of any person to the register that such person shall have
undergone the prescribed training, and shall possess the prescribed experience, in
the nursing of the sick ; and (b) requiring that the prescribed training shall be
carried out either in an institution approved by the Council in that behalf or in the
service of the Admiralty, the Army Council, or the Air Council; and (c) enabling
persons who, within a period of two years after the date on which the rules to be
made under the provisions of this paragraph first come into operation, make an
application in that behalf (in this Act referred to as " an existing nurse's applica¬
tion ”), to be admitted to the register on producing evidence to the satisfaction of
the Council that they are of good character, are of the prescribed age, and either

(i) are persons holding certificates from the Local Government Board for Scotland
or from the Scottish Board of Health (in this Act referred to as “the Board”)
that they possess the qualifications required by the Department so certifying, or

(ii) are persons who were for at least three years before the first day of November,
nineteen hundred and nineteen, bond fide engaged in practice as nurses in attendance
on the sick under conditions which appear to the Council to be satisfactory for the
purposes of this provision and have adequate knowledge and experience of the
nursing of the sick.

(3) Before making rules under this section with respect to the conditions of
admission to the register, the Council shall, with a view to securing a uniform
standard of qualification in all parts of the United Kingdom, consult with any
Nursing Councils which may be established by Parliament for England and Wales
or Ireland respectively.

(4) Rules made under this section shall not come into operation unless and
until they are approved by the Board.

(5) At least thirty days before making any rules under this section, notice of
the proposal to make the rules, and of the place where copies of the draft rules
may be obtained, shall be published by the Council in the Edinburgh Gaeette, and
in such other manner as the Council think best adapted for ensuring publicity.

(6) Every rule made under this section shall be laid before each House of
Parliament forthwith, and, if an Address is presented to His Majesty by either
House of Parliament within the next subsequent twenty-one days on which
that House has sat next after any such rule is laid before it praying that the
rule may be annulled or modified, His Majesty in Council may annul or modify
the rule, and, if annulled, it shall thenceforth be void, and, if modified, it shall
thenceforth have effect as so modified, but without prejudice to the validity of
anything previously done thereunder.

4.—(1) The Council may, with the previous sanction of the Board, appoint
a person to act as registrar of the Council, and may, subject to the consent of the
Board as to numbers, employ such other officers as the Council consider necessary.
The registrar shall act as secretary and treasurer to the Council, and shall be
charged, subject to the instructions of the Council, with the preparation, correc¬
tion, and custody of the register.

(2) There shall be paid to the registrar and the other officers of the Council such
salaries or remuneration as the Council with the approval of the Board may
from time to time determine.

(3) Any expenses incurred by the Council in carrying this Act into effect,
including expenses in connection with examinations under this Act and, subject
as hereinafter provided, the travelling expenses of and sums paid on account of
subsistence allowance to members of the Council, shall be defrayed out of the sums
received by the Council by way of fees under this Act, or any other sums received
by the Council:

Provided that the amount to be allowed to members of the Council in respect of

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travelling expenses and subsistence allowance shall be calculated in accordance
with directions to be given by the Board.

(4) The accounts of the Council shall be made up annually as at such date as
the Board may fix, and shall be audited in such manner, and by such person, as
the Board may from time to time direct, and copies of the accounts, and of any
report made on the accounts, shall, within three months after the date as at which
the accounts are made up, be transmitted by the Council to the Board and to
such persons as the Board may direct.

Provided that—( a ) in the case of an existing nurse’s application the amount of
the fee payable on the application shall be such sum, not exceeding one guinea, as
the Council, with such approval as aforesaid, may determine ; and (A) the amount
of the fee payable in respect of the retention in any year of the name of any person
on the register shall not exceed two shillings and sixpence.

(2) The Council may charge for any certificate or other document issued, or in
respect of any services performed, by them, such fees as may be prescribed.

6. —(i) Any person who proves to the satisfaction of the Council that he has
been registered either generally as a nurse for the sick or as a nurse of some
special class in any part of His Majesty’s dominions outside the United Kingdom,
being a part of those dominions to which this section applies, shall be entitled, on
making an application in the prescribed manner and paying such fee, not being
greater than the fee payable on ordinary applications for registration under this
Act, as the Council may demand, to be registered in a corresponding manner
under this Act.

(2) This section applies to any part of His Majesty's dominions as respects
which the Council are satisfied—(a) that there is in force therein an enactment,
or a provision of any kind having the force of law, providing for the registration
of nurses under some public authority; (b) that persons registered under this Act
are admitted to the register established under the said enactment or provision on
terms not less favourable than those contained in subsection (1) of this section;
and (c) that the standard of training and examination required for admission to
the register of nurses established under the said enactment or provision is not
lower than the standard of training and examination required under this Act.

(3) In the event of provision being made for the establishment of a register
of nurses in England and Wales or Ireland, the Council shall make rules under
this Act enabling persons registered as nurses in England and Wales or Ireland,
as the case may be, to obtain admission to the register of nurses established under
this Act.

7. —(1) Any person aggrieved by the removal of his name from the register may,
within three months after the date on which notice is given to him by the Council
that his name has been so removed, appeal against the removal in manner pro¬
vided by Act of Sederunt to the Court of Session, and on any such appeal the
Court may give such directions in the matter as it thinks proper, including directions
as to the costs of the appeal, and the order of the Court shall be final and
conclusive and not subject to an appeal to any other court.

(2) Any person aggrieved by the refusal of the Council to approve any insti¬
tution for the purpose of the rules under this Act relating to training may appeal
against the refusal to the Board, and the Board, after considering the matter,
shall give such directions therein as they think proper, and the Council shall comply
with any directions so given.

8. —(1) Any person who—(«) not being a person duly registered under this Act,
at any time after the expiration of three months from the date on which the
Board gives public notice that a register of nurses has been compiled under
this Act, takes or uses the name or title of registered nurse, either alone or
in combination with any other words or letters, or any name, title, addition,
description, uniform, or badge, implying that he is registered under this Act or is
recognised by law as a registered nurse; or (A) being a person whose name is
included in any part of the register, at any time after the expiration of the period
aforesaid takes or uses any name, title, addition, description, uniform or badge, or

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otherwise does any act of any kind, implying that his name is included in some
other part of the register; or (c) at any time with intent to deceive makes use of
any certificate of registration as a nurse issued under this Act to him or any other
person, shall be liable on summary conviction to a penalty not exceeding, in the case
of a first offence, ten pounds, and in the case of a second or any subsequent offence
fifty pounds.

(2) If any person wilfully makes, or causes to be made, any falsification in any
matter relating to the register, he shall be guilty of a crime and offence and shall,
on conviction thereof, be liable to a fine not exceeding one hundred pounds.

9. —The Council shall present to the Board a report of their proceedings during
each year within three months after the termination of each year, containing such
particulars as the Board may direct.

10. —(1) This Act shall extend to Scotland only.

(2) This Act may be cited as the Nurses Registration (Scotland) Act, 1919.

Schedule.

Constitution of Council.

1. The Council shall consist of fifteen members.

2. On its first constitution the Council shall be composed of the following
persons, namely:

One person, who shall not be a registered medical practitioner, or a nurse, or
a person concerned with the regular direction or provision of the services
of nurses, appointed by the Privy Council:

One person appointed by the Scottish Education Department:

Four persons appointed by the Board, after consultation with persons and
bodies having special knowledge and experience of training schools for
nurses, of the work of matrons of hospitals, of general and special nursing
services, and of general and special medical practice:

Nine persons, who are or have at some time been nurses actually engaged
in rendering services in direct connection with the nursing of the sick,
appointed by the Board after consultation with such associations or
organised bodies of nurses or matrons as appear to the Board to repre¬
sent persons who may become registered under this Act. The Board in
making appointments under this provision shall have regard to the
desirability of including in the Council persons having experience in the
various forms of nursing.

3. The first members of the Council shall hold office for such term, not less than
two years and not exceeding three years from the commencement of this Act, as
the Board may determine.

4. After the expiration of the term of office of the first members of the Council,
the Council shall be composed of six persons appointed respectively by the Privy
Council, the Scottish Education Department, and the Board as aforesaid, and of
nine persons, being persons registered as nurses under this Act, elected in the
prescribed manner by the persons so registered at the date of election.

5. Any members of the Council other than the first members thereof shall hold
office for a term of five years.

6. If the place of a member of the Council becomes vacant before the expiration
of his term of office whether by death, resignation, or otherwise, the vacancy shall
be filled, if the vacating member was an appointed member, by appointment by the
body or persons by whom the member was appointed, or if the vacating member was
an elected member in such manner as may be prescribed.

Any person appointed or elected to fill a casual vacancy shall hold office only so
long as the member in whose stead he is appointed or elected would have held office.

7. Any member ceasing to be a member of the Council shall be eligible for
re-appointment or re-election.

8. The powers of the Council may be exercised notwithstanding any vacancy in
their number.

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[July,

CONVALESCENT FUND FOR MENTAL NURSES.

(1) The Medico-Psychological Association have accepted the balance of
the Convalescent Fund of the late Asylum Workers’ Association amounting
to £7g 17s. id. to be administered by a special committee on, as far as possible, the
same lines as formerly.

(2) The object of the Fund is to assist mental nurses in obtaining necessary
rest and change at health resorts during convalescence from illness.

(3) All mental nurses, male or female, actually engaged in the practice of their
profession, whether in mental hospitals, institutions for mental defectives or in
private nursing, are eligible for grants from the Fund—usually £3 for a fortnight's
expenses.

(4) Applications for grants should be made personally in writing to the General
Secretary, M.P.A. 11, Chandos Street, Cavendish Sq., W., or to Dr. J. F. Powell,
Mental Hospital, Caterham, Surrey, enclosing a medical certificate (made out on
the official form, copies of which can be obtained from the General Secretary, or
from Dr. J. F. Powell) signed by the Medical Superintendent or other medical
officer in charge, or in the case of private nurses of the insane or mental defectives,
by the medical practitioner who has been in attendance.

(5) The Treasurer of the Association will be empowered to draw cheques on the
Fund for the amount of grants which may be decided upon by the Committee, or
by the member of the Committee appointed to receive applications for grants.

(6) Medical Superintendents are requested to make known to their staff the
above details concerning the Fund, and the procedure necessary in obtaining grants
therefrom.

May, 1920.

(Signed)

G. E. Shuttleworth,
James Chambers,

R. Worth,

J. Farquharson Powell,

M.P.A. Conva¬
lescent Fund
Committee.

OBITUARY.

Dr. Wilson Eager,

Late Resident Physician and Superintendent of Suffolk County Asylum, Melton

(now St. Audry’s Hospital).

We regret to record the death of Wilson Eager, which took place at his
residence in Woodbridge, Suffolk, on 11th May, 1920.

He was born on the 10th May, 1845, the son of Dr. Richard Eager, a surgeon in
Guildford, Surrey. Wilson Eager and his elder brother, Reginald Eager, were
both medical students at Guy’s Hospital, and both eventually made their life-work
the study of mental disease and the care of the insane. Dr. Wilson Eager, having
obtained his L.S.A., L.R.C.P., and M.R.C.S. qualifications in 1871, was Clinical
Assistant at Bethlem Hospital. From here he obtained a post as Assistant Medical
Officer at the Prestwich Asylum, near Manchester. It was from this institution
that he was appointed Resident Physician and Superintendent of the Suffolk
County Asylum, Melton (now St. Audry’s Hospital), a position from which he
retired in 1897, after twenty-one years’ service. During his period of office as
Medical Superintendent he was responsible for a great many improvements in the
lighting, heating and structural arrangements of this institution, which during the
latter part of the eighteenth century had been the Woodbridge Workhouse.

Bare brick walls, which gave a prison-like appearance, were plastered and
painted, and windows added wherever possible. Fireplaces, which were previously
scantily provided, were enlarged and increased in number, and overmantels, made
in the institution workshops, were erected over each.

Quite a feature of the place was the large bird-cages made on the premises con¬
taining some of the prettiest of the feathered tribe, which won the attention of
many patients during the day.

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When Dr. Eager resigned his office, each ward in the institution was self-
contained—a contrast to the state of affairs when he was appointed Medical
Superintendent there, at which time none had either storeroom or scullery, and
goods were frequently stuffed away under the stairs. Besides being an
administrator, Dr. Eager was of an inventive frame of mind. He introduced into
the institution many ingenious contrivances for nursing, amongst which should
be mentioned a means by which baths could be emptied and made ready for a
second patient in one minute—an important detail when large numbers of patients
have to be bathed in batches under nurses’ supervision.

Dr. Eager also took a warm interest in the social life of the institution. He was
of a musical disposition, and many old pensioners of that institution will recall the
enthusiasm with which he used to superintend and take part in concerts and
theatricals provided for the enjoyment of the patients. It was during his period
of residence that a very fine dancing-room with stage was provided for this purpose,
and through his personal efforts he secured an excellent organ for the chapel
costing £300.

On his retirement he was the recipient of handsome presents from the staff of
the institution, and nothing could better serve to emphasise Dr. Eager’s popularity,
kindness of heart and readiness to help ail under him than the expressions of
regret that he received on that occasion.

On leaving county asylum work, Dr. Eager joined his brother in partnership at
Northwood Private Asylum, near Bristol, but, after ten years, he decided to retire
and return to live in Woodbridge, Suffolk, where he had many friends.

He leaves a son, Dr. Richard Eager, O.B.E., who is Deputy Medical Super¬
intendent of the Devon Mental Hospital, and a married daughter who has been
living with him in Woodbridge for many years. His wife predeceased him by
twelve years.

An obituary notice of Dr. J. Batty Tuke, of New Saughton Hall, Midlothian,
who died on April 11th, will appear in the October number.

NOTICES OF MEETINGS.

Annual Meeting.

The Buxton Town Council have officially invited the Association to hold their
Annual Meeting there this year.

Monday, July 26th .—Committee commence at 2.30 p.m. in Town Hall, Buxton.
If Council business is finished by 5 p.m., General Meeting at 6 p.m., adjourn 7.30.

Tuesday, 27th .—Spent at Cheddleton. Char-a-banc leaves Palace Hotel, Buxton,
9.15 a.m. (Return fare 8s., or less according to numbers.) General Meeting
11 a.m.; Lunch 1.15 p.m., Presidential Address, 2.15 p.m., Garden Party 3.30 p.m.
Visit to Silk Mill in Leek for Ladies 10.30 a.m.

Wednesday, 28 th .—Scientific discussions, Town Hall, Buxton, 10 a.m. Half¬
day excursion for Ladies in the forenoon. The Buxton Town Council and High
Peak Medical Society invite Members and Guests to a reception in Town Gardens
3.30-5.30 p.m. Annual Dinner at Palace Hotel, Buxton 8 p.m. (Ladies of
Association included). Tickets 15s. without wine.

Thursday, 29 th. —Full-day excursion to Haddon Hall and Chatsworth. If more
papers are promised, so that a meeting on Thursday morning becomes desirable,
half-day excursion will be arranged for Thursday afternoon, and the Haddon Hall
excursion on Friday if Members will stay, in view of the fact that the following
Monday is Bank Holiday.

HOTEL ARRANGEMENTS should be made at Buxton at once, as the end of
July is the height of the local season and lodgings become unobtainable.

The following hotel accommodation at Buxton is recommended: Palace Hotel,
Crescent Hotel, St. Ann's Hotel, Buxton Hydro, Haddon Hall Hydro, Oliver’s
Hydro, Sandringham Hotel, Milton House, Old Hall Hotel, Shakespeare Hotel,
Pendennis, George Hotel, Pavilion.

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Divisional Meetings.

South-Eastern Division. —October 14th, 1920, Three Counties Asylum, Arlesey,
Beds.

South-Western Division. — October 29th, 1920; April 24th, 1921.

Northern and Midland Division. —October 21st, 1920, The Coppice, Nottingham;
April 21st, 1921, Gateshead Mental Hospital, Stannington.

Irish Division. —November 4th, 1920, College of Physicians, Dublin ; April 7th,
1921 ; July 7th, 1921.

APPOINTMENTS.

Culpin, M., M.B., B.S.Lond., Lecturer on Psycho-neuroses, London Hospital
Medical College.

Evans, G., M.B.Lond., Medical Superintendent, Brentwood Mental Hospital,
Brentwood, Essex.

Sutcliffe, J., M.R.C.S.Eng., L.R.C.P.Edin., Medical Superintendent, Cheadle
Royal Hospital for Mental Diseases, Cheshire.

NOTICE TO CONTRIBUTORS.

Writers are reminded that, according to Lix(a) of the Articles of Association,
" all papers read at the Annual, General, or Divisional Meetings of the Association
shall be the property of the Association, unless the author shall have previously
obtained the written consent of the Editors to the contrary.”

Papers read at Association Meetings should not, therefore, he published in other
Journals without such sanction having been previously granted.

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THE

JOURNAL OF MENTAL SCIENCE

[Published by Authority of the Medico-Psychological Association
of Great Britain and Ireland.']

No. 275 [ n no" 3 T‘] OCTOBER, 1920. Vol. LXVI.

Part I.—Original Articles.

The Mechanism of Involutionary Melancholia. The Presidential
Address at the Annual Meeting of the Medico-Psychological
Association of Great Britain and Ireland, held at Buxton on
July 26th-28th, 1920. By W. F. Menzies, M.D., B.Sc.Edin.,
F.R.C.P.Lond., Medical Superintendent, Stafford County Mental
Hospital, Cheddleton, near Leek.

At a time like the present, when the claims of psychogenic treat¬
ment are attracting the attention not only of the medical, but also of
the lay mind, it befits those of us who believe that beneath every
mental process there lies a mechanical basis to take careful thought
whether we are altogether blameless if comparatively easily understood
psychological explanations of disease are substituted for the far more
intricate and complex physiological, and to ask ourselves whether we
have in fact always applied to the problems of nervous physics the
knowledge we actually possess. We turn to text-books of mental
diseases seeking enlightenment, and are put off by vague explanations,
no more convincing and far less logical than those advanced by the
psychologist, nor do we find any reference to much work on the
physical nature of mind which has long been known, although, indeed,
twenty years ago Crookshank made an effort to correlate physical signs
with mental conditions, and five years ago Dunlop Robertson drew
attention to the importance of adrenalin in the production of depres¬
sion. We do not know much about nerve action, but we do know
something, and if we are not willing to apply to our own special work
the simpler tests of the physiologist and the chemist we are in danger
of seeing our teaching discredited; and therefore I have decided to
address you to-day upon one class of mental illness which comprises
two distinct processes, and to endeavour, by tracing the conditions present
in both, to offer some explanations, not indeed of the ultimate, but
LXVI. 24

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INVOLUTIONARY MELANCHOLIA,

[Oct.,

of the proximate causes which may underlie each in turn. The two
processes are involution and depression, and my title is: “The
Mechanism of Involutionary Melancholia.’’ None of my facts are
new, none have been worked out by any special labours of mine, but
as there may be some who, like myself, banished in the depths of the
country and many hours distant from a medical library, find a difficulty
in marshalling current knowledge into its ordered place, I give these
deductions for what they are worth; for the psychology of melancholia
is the depressive emotion, and the anatomy of the depressive emotion
is a sympatheticotonus, and the chemistry of a sympatheticotonus is
an endogenous anoxaemia.

For the many clinical and laboratory observations required I am
greatly indebted to my assistant medical officers, Drs. W. D. Wilkins
and W. G. Thomson, to whom I tender grateful thanks.

Enterostasis.

In states of depression occurring at the involutionary period a most
important factor is excessive putrefaction in the intestine, and it
becomes necessary to consider the conditions under which this may
occur, for although in old age constipation and dementia are common,
yet only a few old people become depressed.

A good many years ago a former student of Sir William Arbuthnot
Lane asked me if all the insane had intestinal stasis. Without going quite
so far as this it is certain that the condition is very common, and
probably in involutionary melancholia universal. The bands and fine
adhesions are there, plainly to be seen at any post-mortem if looked for,
and sometimes the dilatation and elongation of the intestine are
remarkable. Generally, however, owing to the simple and regular
dietary and the constant avoidance of constipation, together with the
prolonged bed period before death, asylum cases show a jejunum and
ileum shrunken in diameter or length, although the colon is often
much enlarged, and the wall atrophic and even translucent. And on
account of this care appendicitis is not common, although on one
occasion we had three such operations here in a week.

Lane explains the formation of the kinking and bands on mechanical
lines, due first to incorrect feeding and later to the assumption of the
erect posture. Usually the earliest adhesions to form are round the
caecum and lower end of the ileum, and these often implicate the
appendix, leading to operative interference. The process is defensive
against the tendency of the loaded caecum to drop into the true
pelvis, and the bands may anchor the gut to the peritoneum. As the
strain spreads upwards and to the left along the colon adhesions to the
peritoneum tend to form in accordance with the position indicated by
the parallelogram of forces, especially at the hepatic and splenic

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BY W. F. MENZIES, M.D.

357

flexures. Sometimes the middle of the transverse colon is supported,
but generally this drops as a loop nearly or quite to the true pelvis,
causing acute kinking at the hepatic and splenic flexures. The strain
is still further propagated upwards through the gastrocolic omentum and
so to the gastrohepatic omentum, interfering with the peristalsis of the
stomach. Meanwhile the most important of all the results is occurring
—constriction and obstruction of the terminal ileum—whose coils often
lie normally in the pelvis. Thus the contents of the small intestine are
gradually dammed back, leading to distension of the gut and stretching
of the mesentery, until a jejunoduodenal kink occurs and the free
first and second parts of the duodenum dilate, the resultant adhesions
interfering with the outflow of pancreatic juice and bile and constricting
the pylorus. In the end there is general dilatation, kinking and stasis
throughout the whole intestine, involving even the sigmoid. The bands
connect loops of intestine to one another or to the anterior or posterior
lining of the abdomen.

But one has never felt that Lane’s explanation of these conditions in
the first and even the second decade of life has been quite satisfactory.
In young neurotic patients it is sometimes possible to make out an
undue breadth of colon, dropping below the umbilicus, unequal dilata¬
tion of the stomach, with exaggerated flexion at the angular notch,
doughiness in right or left flank, and tonic contraction of one or other
rectus muscle; and this where no symptoms of stasis are present and
where the bowels are moved daily. Lane holds that the adhesions are
evolutionary, not inflammatory, while Keith believes that enterostasis
is associated with the presence of nodal segments throughout the
intestine. He shows that at each node there is a special development
and modification of the cells of the myenteric plexus, and quotes
Alvarez’ researches as to the action of the nodal segments, movement
in any one of which causes, as Bayliss and Starling demonstrated,
inhibition in the next segment. He also recalls Jordan’s radiographic
evidence, and agrees with Hurst that where obstruction takes place
there are no mechanical means to prevent it. He finds there are at
least four rhythmical zones—duodenal (commencement of second part),
jejuno-iliac, proximal colic and distal colic, and probably also an ceso-
phageal and a gastric. Finally he puts forward his theory of enterostasis
as being opposed to that of Lane. But may not both be right ?
Embryologists are far from agreed as to the representation in the
modern intestine of the various portions of the primitive body cavity.
May not the fourth and fifth branchial ridges have carried stomodceal
elements down to the duodenum, or the anal infold have taken procto-
doeal elements back as far as the ileum ? If so they would include in
their sphincters ectodermal tissue, in their continuity endodermal, the
former excited by the sympathetic and inhibited by the autonomic, the

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latter excited by Auerbach’s plexus and inhibited by the splanchnics.
May not enterostasis be caused at first by a neurohormonic disturbance,
and afterwards, when the muscular and nervous structures have been
thrown out of gear, maintained by a mechanical ? But whatever the
original cause of the stasis nervous impulses cannot produce the bands;
the irritant must be either mechanical or chemical.

We need not recite the various diseases ascribed by Lane to entero¬
stasis, but the signs and symptoms we meet with constantly—asthenia,
anorexia, nausea, headaches, loss of weight, defective circulation, dr)’
and atrophic skin, constipation, bronzing, mammary fibrosis, adventitious
hair, torpor, apathy or depression. Many occur in the various psychoses
or in senility, and in all probability most visceral delusions are founded
upon abdominal discomfort.

It is recognised that the products of food metabolism are unlikely to
produce harmful effects. Peptones and proteoses are eminently toxic
when injected intravenously, producing effects allied to anaphylactic
shock, but these bodies never occur normally in the blood. Products
of bacterial digestion are more important. It has long been known
that putrescine and cadaverine are thus formed from the diaminoacids
ornithine and lysine, and more recently that decarboxylation of amino-
acids produces a whole series of poisonous aromatic bases, chiefly
derivatives of the benzene and pyrrol rings. Ackermann, Mellanby,
Twort and others have demonstrated the production of histamine from
histidine, but Barger and Dale maintain that there must be a mechanism
whereby this strongly depressor substance is prevented from entenng
the circulation. Herter, Vaughan Harley and others attribute the
neurasthenia and melancholia of chronic constipation to the long-
continued absorption of indol, skatol or phenol, while Woolley and
Newburgh find that the only result of this is an increase of chromaffine
tissue. Adami attributes far greater importance in producing chronic
bacterial changes to subinfection, wherein bacteria in a particular state
of attenuation may be absorbed and carried by the blood or lymph to
distant parts, forming local capillary infarcts, and are there attacked by
the phagocytes. Some are killed, and the discharged toxins kill the
rest, so that no bacterial proliferation or general intoxication occurs (
but the bacteriolysis also kills some of the more highly organised tissue-
cells in the immediate vicinity, the reaction producing the usual growth
of indifferent replacement tissue. By this means Rosenow has produced
artificial rheumatoid and myositic lesions in rabbits, which, as Luff
points out, are of the same nature as the irritative connective-tissue
hyperplasias which occur in human chronic rheumatic affections. Opie
has similarly produced hepatic cirrhosis, and Gaskell, Aschoff, Libman
and Baehr have shown that certain forms of nephritis are produced by
streptococcal emboli in the finer capillary loops of the glomeruli.

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BY W. F. MENZIES, M.D.

359

Stokvis. Gibson and others showed that the products of Bacillus coli
invasion produced pigmentation, while the work of Farrant, and
especially the careful observations of McCarrison, prove that another
result is hyperthyroidism, followed later by atrophy, so that, as Horsley
and Rolleston remark, in old age the thyroids degenerate and the
adrenals get too big a pull.

Chetham-Strode and Benjafield attack the bacteria in the intestine.
They allege that the coarse, non-sporing, Gram-positive bacteria of the
Bulgar group especially produce lactic acid, but that the growth of
these is inhibited by Gram-negative bacilli of the colon group, and by
others such as proteus, or Streptococcus fcscalis. Consequently, by
feeding with coarse, undercooked carbohydrates, by non-antiseptic
laxatives, by abdominal massage, and by autogenous vaccines they
claim to be able to raise the ratio of the Bulgar group from i : 250 to
1 : 5, with relief of many of the symptoms of enterostasis. The effect
of lactic acid brings us back to the work of Metchnikoff, and the
fashion, some years back, of attempting by its exhibition to secure all
the benefits of eternal life. The real valuej however, is claimed to lie
in its power of counteracting the toxins of the coli group, and so diminish¬
ing the ill-effects of enterostasis.

To understand the connection between bacterial absorption and
melancholia it is essential to have an anatomical basis to work upon,
and this is found in the involuntary nervous system. This system has
been in fashion of late, and many books have been written blaming or
praising it, as the case may be, for half the ills or benefits to which
human flesh is heir. Yet it is impossible to over-estimate its
importance.

The Involuntary Nervous System.

Much confusion has been created by the use of different names by
various writers, not only for the.whole system but for its two contrasted
parts. Gaskell called the whole the “involuntary”; Langley, who has
done more than anyone else to develop our knowledge of its functions,
groups it all under the term “ autonomic.” In America chiefly the
name “ vegetative ” has been applied to the whole, and the terms
“ parasympathetic ” and “ sympathetic ” to the parts. Cannon does not
fully distinguish in every case, often calling either the “ sympathetic.’’
None of the names are wholly satisfactory or entirely applicable, but as
most of the system acts independently of the will I propose to adhere
to the term “ involuntary ” for the whole system, to call the bulbosacral
outflow the “ autonomic,” and the thoracicolumbar the “ sympathetic,”
as was somewhat tentatively adopted by its first great exponent, Gaskell,
who, opposing in many fundamental points the views of His and his
school, traced it from the original position in the early segmented

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360 INVOLUTIONARY MELANCHOLIA, [Oct.,

invertebrate. In the primitive animal we may imagine two nervous
masses, one in front of the mouth-part concerned with orientation and
the other behind it concerned with mastication. The mouth-part led
into the body cavity, an epithelial tube or infundibulum, concerned
with alimentation, circulation and respiration. This tube persists
to-day as the central canal of the ventricles and spinal cord. The
suprainfundibular mass, or snout-sense organ, at first olfactory in
nature, later on became optic, then auditory. The infrainfundibular
mass developed, as segments were added, prosomatic and meso-
somatic parts, the former concerned with mastication, the latter with
respiration. The original absence of differentiation of the special
senses is illustrated by modern hydromedusre, some of which possess
an optic vesicle, others an auditory or touch-localisation pit, but both
never appear in the same species (Shipley). An interesting state of
deadlock may be observed in some highly developed invertebrates
such as scorpions and spiders, where the fused mass of suprainfun¬
dibular, infrainfundibular and crural ganglia has come so to constrict
the oesophagus that this has narrowed to a tube fit only for blood¬
sucking. Further cephalisation is impossible without starvation, the
chance of developing a new ventral alimentary tract being gone for ever.

In the lowest vertebrates the notochord and infundibulum limit the
forward development of the epichordal or infrainfundibular mass from
which alone the segmental cranial nerves arise; these are joined, by
primitive crura round the infundibulum, to the prechordal or suprainfun¬
dibular parts, subserving sight and smell. The early vertebrate, therefore,
set out to acquire a new intestine untrammelled by cephalic constriction,
and this in its origin is closely connected with the respiratory chamber,
whose appendages were supplied with somatic segmental nerves. The heart
was still close to the mouth, and developed from the original common
body cavity, the cloaca was close to the respiratory chamber, and ulti¬
mately became connected with it by a short tube developed from the
mid-vertebral groove, and carried with it during development a portion of
the ectodermal contractile tissue. As the body cavity lengthened the
cloaca moved hinderward, carrying with it its muscles and nerves.
The latter still exist along the intestine as Auerbach’s plexus, a part of
the autonomic system, the former especially as sphincters of the gut,
innervated from the sympathetic. The fore-gut formed several evagina-
tions, viz., lungs, liver and pancreas; the hind-gut, on the other hand,
arose from the segmental duct, consisting of three chambers,
coprodceum, urodceum and proctodoeum. The original segmental
duct, or pronephros, split into the Mullerian duct, conveying generative,
and the Wolffian duct, conveying excretory products ; these are the
mesonephros. Later a metanephros, or kidney, was added, and
bladder and cloaca became separated.

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BY W. F. MENZIES, M.D.

361

The origin of the intestine (as thus shortly summarised) is intimately
connected with the lateral group of nuclei from which the segmental
cranial nerves arise. In some invertebrata, such as the crayfish, these
nerves supply each an appendage and nothing more, and contain motor
and sensory fibres, constituting the branchial supply. But there is also
another pair of nerves, also containing motor and sensory fibres, and
supplying the voluntary muscles and skin. So that there comes to be
in both prosomatic and mesosomatic parts nerves belonging to both
somatic and branchial segmentation, and each possessing motor and
sensory functions. As the vertebrate body lengthened out more
segments were added posteriorly, but these, not being derived from the
appendages, no longer took on a somatic and splanchnic representation,
but their nerves take origin in the anterior and posterior cornua of the
cord.

In the primitive animal the contractile tissue, undifferentiated
neuromyotomes, lay round the body cavity very near the nerve chain.
As the muscles developed or were pushed peripherally by growing cell-
masses they took in many cases the nerves with them. Some of these
ganglia moved a long way, such as the superior and inferior cervical,
the solar plexus, superior and inferior mesenteric ganglia, cardiac, renal
and Auerbach’s plexus; some went only a short way, such as the
posterior root ganglia and those of the lateral sympathetic chain. It
need not here be discussed whether the original nerve-cord was
segmented (Gaskell), or whether it was continuous and the ganglia
formed by stretching in connection with a blood-vessel (Anderson); the
important point is that the lateral chain ganglia are motor in function
and originally lay within the cord, being differentiated out by devolution
of function, and that the posterior root ganglia form their sensory
complements.

The gangliated cord is connected to the spinal cord by grey and
white rami communicantes: the grey are post-ganglionic fibres, the
white are pre-ganglionic. A few of the grey rami pass into the cord,
mainly by the posterior roots, and are distributed to the pia mater;
their function is vasomotor, none enter the cord paths. The bulk of
the grey rami pass peripherally with the spinal nerves, and are
distributed segmentally with them. The white rami are sensory and
motor. The former pass only to the posterior root ganglia, the latter,
passing to the anterior roots, are found (a) in the spinal accessory
root, whence they may be traced to the vagus, ( b) in the thoracico-
lumbar region, (z) in the second and third sacral roots, whence they
may be traced to the pelvic plexus. They are interrupted in the lower
cervical and lower lumbar regions by the fibres to the extremities. A
small group (d) is found in the oculomotor nerve, supplying the
sphincter iridis. They are fine medullated fibres everywhere, different

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[Oct.,

in appearance from the ordinary white fibres, and are the pre-ganglionic
motor fibres of the involuntary nervous system. The three great out¬
flows from the central nervous system may be summarised thus:—

(1) The Oculo-bulbar.—To the ciliary, spheno-palatine, otic and
submaxillary ganglia (prosomatic) ; to the vessels and mucous membranes
of head, the heart (cardio-inhibitory), muscle of lungs, oesophagus, liver,
gall-bladder, stomach and intestine down to end of transverse colon
(motor), constituting the great vagus system (mesosomatic), through the
cardiac, pulmonary and oesophageal plexuses.

(2) The Thoracico-lumbar.—To the superior and inferior cervical
ganglia, the white rami of the gangliated chain, the renal, semilunar,
superior and inferior mesenteric and spermatic (or ovarian) ganglia.
From thence they proceed, mostly as non-medullated fibres:—

(a) To the blood-vessels everywhere, including heart (cardio-
accelerator).

(^) To the involuntary skin musculature.

(c) To the kidney, ureter, bladder sphincter, urethra, uterus
and Fallopian tubes, being the parts arising from the segmental duct.

(d) To the stomach and large and small intestine as inhibitors;
to the liver, spleen, pancreas, adrenals; to the intestinal region,
anus and vagina as motor to sphincters.

(3) The Sacral.—To the pelvic plexus, as motor to the muscles of
intestine, from descending colon to anus, wall of bladder and external
genital organs.

The first and the third constitute the autonomic system, the second
the sympathetic. The autonomic is more local in its supply, the
sympathetic covers practically all the ground of the autonomic, although
it is occasionally local (body walls, limbs, kidney and internal generative
organs). Where this double nerve-supply exists the two systems do not
necessarily act in opposition, although they generally do. Thus in the
external genitals all sympathetic nerves cause contraction, all autonomic
cause relaxation. Much discussion has arisen as to whether there are
afferent fibres in the two systems. Sensation in them is certainly of the
protopathic type and the threshold for pain is high, while most afferent
impulses are unconscious, or at least only affect consciousness under
special conditions, and then indirectly, such as the vascular effects of
emotion. Bayliss first definitely proved that dilatation of skin capillaries
was an afferent impulse and passed in by the posterior roots. The
afferent autonomic fibres overlap the afferent sympathetic in thoracic
viscera, stomach, intestine, liver and pancreas. Most painful stimuli
pass by the sympathetic; few afferent autonomic fibres are distributed by
the vagus below the diaphragm. Considerable differences of opinion
still exist as regards a good many of the activities of the autonomic and
sympathetic divisions, contradictory results having been given by
experiments. It would appear that much of the physiological disagree¬
ment can be explained on the ground of autonomic and sympathetic

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storms and subsequent exhaustion, whereby it may be that under
different conditions of stimulus discordant results appear. Certainly in
man we have no reason to believe that differences of anatomical
distribution alone will fully explain in every case the widely differing
combinations of symptoms which we meet with clinically.

The Physiology of the Emotions.

Among the numerous workers who have helped to enlarge our know¬
ledge of the intimate connection between the involuntary nervous
system and the emotions the names of Pavloff, Cannon and Elliott
stand out prominently. It had, of course, been long recognised that
fear might cause certain superficial presentations, such as pallor, cold
sweat, dry mouth, rising of the hair, rapid heart, quick breathing,
trembling and twitching; that anger or excitement could reproduce some
of these and add others rather different, such as clenched hands, blood¬
shot eyes, flushed face and engorged veins, contracted brows and back-
drawn lips; that anxiety inhibited sexual excitement and that pleasurable
anticipations of food aided appetite. But it is only in comparatively
recent years that systematic efforts have been made to trace the technique.

Pavloff by “ sham feeding” produced a copious flow of gastric juice
in the hungry dog. Even the sight or smell of food caused a psychic
secretion, just as had always been observed in the case of saliva in man
and animals. Following on the flow of gastric juice came pyloric
relaxation, duodenal peristalsis and out-pouring of pancreatic juice and
bile. He also showed that “ conditioned reflexes ” could be set up, so
that, when once the dog had learned the connection, a horn blown in
the next room, or the sight of a specially coloured fluid, became in turn
the alimentary activator. Hornberg showed that the chewing of sapid
morsels caused gastric secretion, but that tasteless substances, like
guttapercha, were ineffectual.^ Bogen found that fear and anger stopped
gastric secretion, and Muller relates the case of a nervous woman who
had indigestion and a feeling of epigastric “ heaviness ” when worried.
Le Coute says excited dogs do not secrete gastric juice, and if the
process has begun excitement stops it. Oechsler showed that the same
effect was produced on the pancreatic secretion. Bickel showed that
gastric secretion persists long after a meal is finished. From the above
examples it is clear that emotional processes inhibit digestion.

The next step is to show that the inhibition caused by the emotional
impulses is closely connected with the activity of the involuntary
nervous system. Cannon found that cutting the vagus inhibited gastric
secretion, but that, once started, vagal section did not stop it. Auer
and Lomrnel confirmed the production of intestinal inhibition by partial
asphyxiation, and Mantegazza found that pain caused vomiting and
diarrhoea only if the vagi were intact. Cannon found that stimulation

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of the cut splanchnic inhibited intestinal movements, caused con¬
striction of the internal generative organs and usually relaxation of the
bladder. Pavloff showed that stimulation of the cut vagus caused a
flow of gastric juice, the salivary glands received more blood, and
intestinal movements were increased. Cannon showed that dilatation
of pupils was effected by an electrical stimulus too feeble to cause
erection of the hair, also that sacral stimulation emptied the colon and
bladder. Langley and Anderson showed that sacral stimulation had no
effect on the internal generative organs, that thevasa deferentia, seminal
vesicles and uterus had to all intents only a sympathetic nerve supply,
and that the sphincters and external generative organs were stimulated
by the splanchnics. The mechanism of the involuntary nervous system
in producing and carrying on the various processes of internal economy
seemed to be settled when Bayliss and Starling proved that all the
phenomena of digestion in the mouth, stomach and duodenum could
be stimulated if an acid fluid were applied to the duodenal mucous
membrane after section of the nerves. This was the first intimation
that another important factor was at work in body processes, and they
named the agents “ hormones ”; these bodies have since been shown
to be widely utilised in the animal economy. But while this is so it
still remains true that the involuntary system is necessary for the full
and regular performance of most internal functions. The two divisions
exhibit generally a difference of distribution, the autonomic fibres
supplying more restricted areas, and being able to act selectively, as in
the three pelvic organs, the bladder, penis and rectum, while the
sympathetic fibres arise from many contiguous spinal roots and are
apparently designed rather for massed effects. The sympathetic
influence can generally overcome the autonomic, but does not persist
so long, so that in an organ reciprocally innervated the different condi¬
tions present at any one time may explain the different and divergent
results observed under experiment. Cannon concludes that the use of
the autonomic system is the quiet building-up of the body reserves
against a time of stress, and that its operations have little result on the
affective tone. From this point of view it is hardly to be wondered at
that his explanation of the copulation complex is unconvincing.

The third step is to show that many of the phenomena which are
produced by emotion and also by nervous outflow from the involuntary
system are closely duplicated by the effects of adrenalin, attention to
which was first drawn in 1894 by Oliver and Schafer.

The Adrenals .—Chromaffine tissue appears in the cyclostomata
(lamprey) as thin strips on the arterial walls. In elasmobranchs (ray)
groups of such chromaffine cells are segmentally arranged close to the
corresponding ganglia of sympathetic nerves, while cortical tissue is
represented by a pair of organs in the kidney region. In the frog the

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cortex and medulla first begin to come together, but it is only in the
higher mammals that complete encapsulation of the medulla by the
cortex occurs. The cortex and medulla are developed from different
sources, the cortex from the endoderm of the primitive coelum, and
more particularly from the mesonephros, the medulla from the ectoderm
as part of the sympathetic nervous system. The adrenals are supplied
by pre-ganglionic fibres,land the medulla is a special adaptation of
sympathetic nerve-cells. It is the medulla which secretes adrenalin.

Old experiments showed that adrenal extract relaxed smooth bron¬
chiole muscle, counteracted fatigue, drew blood from the viscera into
the lungs, central nervous system and skeletal muscles, hastened
coagulation, and increased the sugar release from the liver. Jacobi traced
splanchnic fibres into the adrenal glands, Biedl found that these
conveyed vasodilator impulses, Dreyer found that secretory results
also accrued. Tscheboksaroff found that blood from the renal vein
contained more adrenalin after splanchnic stimulation. Ascher found
that if the adrenal veins were obstructed general blood-pressure did
not rise. Elliott showed that if the adrenals were removed pupillary
dilatation did not occur; also that if one splanchnic were cut and the
animal then excited the intact gland contained less adrenalin than the
one whose nerve had been severed. Cannon found that if the
abdominal vessels were ligatured after injecting adrenalin the general
blood-pressure did not rise; also that the inferior vena cava blood
from an excited animal inhibited electrical contraction in abdominal
muscle, but that blood from the renal vein had no such action; nor
did the inhibition occur if the adrenals had been previously removed.
Bang found that asphyxia, pain and excitement increased the blood-
sugar, Starkenstein showed that this did not occur after removal of the
adrenals. Macleod suggested that the oxidation of the blood-sugar, by
increasing carbonic acid, reproduced conditions comparable with those
of asphyxia. Elliott found that histamine depleted the adrenals and at
the same time produced all the phenomena of terror.

It is therefore clear from the above evidence than an emotional
outflow is at one with the sympatheticotonus, and is accompanied by
an increase of adrenalin, acting as a hormone.

Glyccemia .—Sugar is stored in the liver cells as the polysaccharide
glycogen. When required to supply energy it is katabolised into
glucose, the aldehyde of the hexahydric alcohol sorbitol. Glucose has
a simple molecule, and is crystalloid. It is generally produced from
the dietetic carbohydrates, but can, in their absence, be produced from
proteins. Under usual conditions adrenalin stimulates the output of
glycogen from the liver, but this can be inhibited by an antagonistic
hormone secreted by the spleen. During dietetic glycogen intake the
pancreatic flow is increased by the hormone secretin, and secretin is
activated by the enzyme prosecretin, formed from the duodenal mucous
membrane by the action of dilute acids. This apparent complication
is an example of the manner in which the body processes are inter¬
woven, hormone (enzyme), secretion and nervous system all interacting
and regulating one another automatically. The pancreas is supplied
to a small extent by the autonomic system, largely by the sympathetic,
and we know that the latter can generally overwhelm the former, so

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what happens is that the sympathelicotonus contracts the gastric and
pancreatic vessels, inhibits secretion and also causes spasm of the
pyloric sphincter, therefore gastric juice is poorly produced, and what
there is cannot reach the duodenum. Hence the inhibitory action of
the pancreas is lowered by want of secretin, and so the adrenalin,
which is at the same time produced in undue quantity, is free to
liberate from the liver an excess quantity of glucose.

It has long been known that severe emotion may produce diabetes,
and very many observers have noted that glycosuria is comparatively
common in melancholia, and that the amount of sugar in the urine
varies with the amount of the depression. Raimann, Schultze, Goodhart,
Bond, Toy and Knauer all produce evidence of this. Hoffmann, and
later Elliott, showed that glycosuria was easily produced in “ excited ”
cats, Cannon found that before an important football match many
players and some spectators were passing urinary sugar, and that the
same occurred during examination time at a women’s college.

But a better indication of the effect of emotion may be obtained
from a direct estimation of the blood-sugar. Normally this may be
taken as varying within comparatively narrow limits, whether when
fasting or after a carbohydrate meal, viz., between ’07 and •12 per cent.
Recently Kooy has published some detailed observations, using the
Bang method of estimation :

Three-quarters An hour and Two hours
Before of an hour a-half after after
breakfast, after breakfast, breakfast, breakfast.

Normals . . ‘098 . ’114 . ‘116 . *104

Melancholics . *113 . *163 . ‘145 . ’119

He gives numerous percentages in other forms of mental disease,
but finds that in melancholia alone is the glycsemia unduly high before
meals, in great excess shortly after a meal, and disappears more slowly
than in the normal individual. Hyperglycsemia is not, of course, to be
looked upon as an actual cause of mental disorder, for if this were so
diabetics would be more often depressed, instead of being on the whole
rather cheerful and hopeful persons, but the percentage of blood-sugar
is a useful index of a good many processes of tissue metabolism.
Raimann found that in both depressed and excited mental states the
power to assimilate glucose was lowered. Kellaway observed an
increased glycsemia in asphyxia, and believed that this was caused by
lack of oxygen and not by excess of carbonic acid. When both
splanchnics were cut anoxaemia produced an increase of both glucose
and adrenalin.

We may now summarise the principal known effects which, combined
with the interaction of hormones, result from the activity of the two
divisions of the involuntary system, viz., the autonomic and the
sympathetic. (1) Effects on involuntary muscle—pupil changes,
regulation of the cardiac beat as regards both frequency and strength,
and of the depth and frequency of respiration, control of the calibre of
arteries and arterioles, thus influencing general vascular tone and the
supply of blood to a part, movements of the stomach, intestines and
bladder, control of the tone of the internal and external generative

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organs, the skin musculature and the pilomotor mechanism. (2) Effects
on glandular secretion, tears, sweat, saliva, gastric and pancreatic juice,
bile, succus entericus, urine, adrenalin, thyroidin, pituitrin, semen,
and prostatic fluid. Most of the actions are reflexes, and both afferent
and efferent paths may lie in the involuntary system or one or other
in the cerebro-spinal; also most of the effects are compound, thus
respiration has to do with tone of vessels and of bronchiole and alveolar
muscle, and glandular secretion is an effect on vessels, capsular muscle
and gland-cells. These reflexes are the ultimate physical foundations
of responses which we know as affective tones, and which, when pre¬
sented in excess of a definite physiological limit, may overflow as a
pyschic state which we call an emotion.

Infracortical Conducting Paths.

If we accept the proposition that an emotion has an important
connection with the involuntary nervous system it is necessary shortly
to consider the general outlines of the conduction of nervous impulses
before they reach the cerebral cortex, and the possible paths by which
those subserving feeling-tone may travel.

Peripheral afferent paths .—It was no exaggeration on the part of
Rivers to remark that Head’s brilliant conceptions of the nature of
sensation added not merely a new page, but an entirely new chapter to
the science of neurology. Head, Rivers and Sherren showed that
three sets of fibres existed in peripheral afferent nerves. (1) The deep
set run chiefly with nerves from muscles and joints, and are devoted
largely to the conduction of impressions which affect essentially deform¬
ations of structure, thus giving information of passive movement and
position ; they also give a fair amount of power of localisation, and
transmit painful stimuli resulting from deep pressure. (2) The proto-
pathic set respond to painful cutaneous stimuli, and to the extremes of
heat (45 0 C. and over) and cold (20° C. and under). They belong to
the great sympathetic reflex system, and produce a response unaccom¬
panied by any definite appreciation of locality. (3) The epicritic set
convey impressions of cutaneous localisation, the appreciation and
discrimination of light touch, and of the finer grades of warmth and
coolness. The areas of distribution do not necessarily correspond, the
epicritic being associated with peripheral nerves, the protopathic rather
with root segments. After injury the protopathic regenerate much
earlier than the epicritic, and this recovery is associated with freedom
from trophic lesions. They evidently belong to a much older and more
primitive developmental order. It will be at once seen that their
functions to a considerable extent coincide with those associated with
the basal ganglia, while the epicritic develop pari passu with the more
recent acquisition of psychical discrimination as centred in the cerebral

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cortex. Not that epicritic sensibility is of necessity a cortical mechanism,
for the decerebrate frog and the spinal dog localise accurately by
means of spinal reflexes ; but that the higher the development of brain
the more sensations of an epicritic nature tend to concentrate therein,
so giving increased range of psychic perception and greater protection
against injury. The presence of heat and cold spots on the skin seems
definitely confirmed, and the correctness of the contentions of Blix,
Goldscheider and von Frey established. Protopathic stimuli exhibit a
higher threshold in the absence of epicritic control, but the response is
more severe and radiates widely. To these we must add (4) conscious
and unconscious visceral sensation, which, although little understood, is
of the nature of protopathic conduction. The high threshold may be
connected with a sparsity of distribution, but the response is wide¬
spread, and tends to cause reflex sympathetic phenomena altogether
out of proportion to the actual pain felt, as the tendency to fainting in
spasm or fissure of anus. Section of the healthy gut is almost painless,
but the pain in inflammatory states may be very severe or altogether
absent. A consideration of these various phenomena has led Ranson
to believe that protopathic fibres are unmyelinated; he states that
they are abundant in the peripheral nerves and also extend up the cord,
largely connected with Lissauer’s tract and the substantia gelatinosa in
the neighbourhood of the posterior roots.

Peripheral efferent paths .—For long the conception of a final common
path from anterior horn cell to periphery, as enunciated by Sherrington,
had been considered as settled, but more recently Ramsey Hunt has
elaborated the theory that there are two distinct systems of motor
fibres to skeletal muscles, (1) the paleokinetic to the sarcoplasmic
substance, associated with slow tonic contraction, and (2) the neokinetic
to the sarcostyles, associated with the quick, spasmodic, “ voluntary
contraction. He holds that the principle is carried right through from
periphery to centre, and is likewise represented in the cerebellum.
Anatomical evidence is adduced from the ventral root fibres in the
thoracic region, which, it is alleged, cannot all be of sympathetic
origin, and also from the comparative ontogenetic myelination of the
roots. Clinical evidence is adduced from the observed differences
between the two forms of muscular hypertonus, rigidity being referred
to striospinal influence, spasticity to corticospinal. These differences
we see daily in the wards in the melancholic or katatonic on the one
hand, and the spastic epileptic on the other. But the two possibilities
still cause much discussion, and cannot be looked upon as settled.

Spinal afferent paths .—In the cord the three sets of fibres—deep,
prbtopathic and epicritic—end at the first intercalary neurone, and
impulses are regrouped so that all sensations of pain, from whatever
source, pass up together, and likewise all sensations of heat, cold, touch
or pressure. The posterior columns are composed of fibres direct from

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the roots, which have not yet entered the grey matter. Some fibres
enter it rapidly, some after a longer or shorter course, some not until
they reach the nucleus gracilis or nucleus cuneatus. Pain, heat and
cold fibres cross in the anterior white commissure and may be
interrupted in syringomyelia. Impressions of pain filter across within
five or six segments and after regrouping pass upwards in the contra¬
lateral posterior spinothalamic and spinotectal tracts of the lateral
column, although a few fibres seem to run in the ipsolateral tracts of
the same name. Heat and cold follow much the same course, but are
more completely crossed. Lesions have been found in cases where
these sensations had been dissociated, but the paths are always in
anatomical proximity. The spinothalamic and spinotectal fibres are
mixed together in their upward course. They send a bundle to the
superior cerebellar peduncle and vermis, fibres and collaterals to the
formatio reticularis, Deiter’s and the lateral nuclei to cerebellum via the
middle peduncle, and to the lateral fillet. The spinotectal fibres end in
both colliculi, the spinothalamic in the ipsolateral ventral and ventro¬
lateral nuclei of the thalamus.

Impulses of touch and pressure do not cross so readily, and for some
distance a double path is thus available; the fibres are found both in
the ipsolateral posterior column and in the contralateral anterior spino¬
thalamic tract of the lateral column. Impulses underlying the sense of
position, passive movement and tactile discrimination do not cross until
they reach the cells of the gracile and cuneate nuclei. As they ascend
they are displaced mesially, so that eventually Goll’s column consists of
fibres from the lower, Burdach’s from the upper extremity. These
columns are continued in the mesial fillet, and after giving fibres to the
inferior olive, formatio reticularis and anterior colliculus, end in the
lateral and ventrolateral nuclei of thalamus.

Unconscious impulses underlying muscular co-ordination and the
reflex tone of involuntary muscle, both in skin and vessels, come in
from the sympathetic system in the thoracicolumbar region and reach
Clarke’s column in the posterior horn. Some then run in the ipsolateral
(direct) dorsal spinocerebellar tract of lateral column to the inferior
cerebellar peduncle, the rest in the contralateral (crossed) ventral
spinocerebellar tract of lateral column to the middle or superior
cerebellar peduncle, probably the latter.

Spinal efferent paths. (1) Pontospinal tract (olivospinal, bulbo¬
spinal).—This tract is stated to be recognisable in degenerations from
the inferior colliculus, or even from the thalamus, to the formatio
reticularis, but the anatomical complications are too great to admit of
positive statements. From the grey formatio the fibres run down the
cord partly in the ipsolateral anterior column external to the vestibulo¬
spinal tract and partly in the contralateral lateral column. Together
with the vestibulospinal the fibres seem to have an important connection
with the maintenance of muscle tone and the erect posture.

(2) Vestibulospinal tract— Sachs considers that this tract may be
traced from the contralateral lateral thalamic nucleus, but this is
probably not so. It is more apparent after Deiter’s nucleus is reached,
and runs down the anterior column, mostly ipsolaterally, as far as the
anterior horn-cells of lower lumbar roots. It myelinates at the end of

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the third month of intrafoetal life (Hosel). The tract first appears in
some of the higher teleostean fishes (Ahlborn) as eight fibres on each
side arising among the cells of the vestibular nucleus, and supplying
the automatic balancing mechanism of the tail muscles. I think it
possible that this mechanism may have something to do with the air-sac
becoming a closed vesicle, for it does not appear in eels, where the
air-sac is still in communication with the intestine.

(3) Tectospinal tract .—This and the vestibulospinal are the
oldest efferent tracts. It appears in the crayfish, lobster and fishes as
“ Mauthnerian ” or “ Mullerian ” giant fibres having to do with balance
by sight. In man it arises in the anterior colliculus, crosses in
Meynert’s “fountain decussation,” and runs down the lateral column as
the ventral longitudinal bundle to the horn-cells of the lower lumbar
roots. It myelinates during the fourth month of intrafoetal life. Its
connection with the optic tract seems to have now disappeared, and
degenerations indicate that it is connected with the cochlear nerve.

(4) Rubrospinal tract (MonakofTs tract).—This tract constitutes
the principal extrapyramidal efferent path, and is the voluntary efferent
path in birds. Starting from the large cells of the globus pallidus, and
intercalating in the nucleus ruber and associated nuclei, it decussates in
Forel’s crossway and runs down the lateral column of cord, anterior to
the crossed pyramidal tract, as far as the sacral roots. It myelinates
during the fifth month of intrafoetal life. It is well developed in
amphibia and reptiles as well as birds, and better in the dog than in man,
being generally present in inverse ratio to the pyramidal. It seems
probable that in some marsupials, where it runs in the posterior
columns, it may have direct connection with the cerebral cortex, for
experiments are described in which section of one crus has produced
four degenerations, two on each side.

(5) Pyramidal tract .—This is the newest efferent tract and is not
fully myelinated until long after birth. The fibres arise as the axons of
the Betz cells in the fourth and fifth layers of the precentral cortex, run
through the crus, decussate at the lower medulla, and run down in the
contralateral lateral column to end round the cells of the posterior
horns, intercalating afterwards to the anterior horn-cells. Part of the
tract does not cross but runs direct down in the ipsolateral anterior
column as far as the mid dorsal region. Some of these fibres come
from the opposite hemisphere via the corpus callosum and have to do
with bilateral shoulder, arm and hand movements. The pyramidal
tract possesses great interest as showing how, with the development of
the neopallium, short-circuiting comes in as a time-saving device ; and
the Betz cells are the most interesting feature in it. Giant cells are
common in the invertebrata, and postulate long axons. In the earth¬
worm the fibres are practically the only means of long distance connec¬
tion between the segments, and exist as three large hollow fibres disposed
round the gangliated cord. In the leech they are chromaffin cells, the
progenitors of the present adrenal body. In crayfish they give rise to
two giant fibres equilibrating the tail, in the lamprey and higher fishes
they appear in great numbers, and lastly they are used in our own
newest tract. And in every case they indicate an organisation not yet
arrived at maturity. In every case they give off collaterals, one fibre

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going to many cells and making possible the so-called “axon-reflex.”
In later developments the Betz cells, in the embryonic stage, subdivide
and the axons become more numerous, thereby still further differen¬
tiating function. In each case this type of neurone is found in the final
collecting station of its group of nuclei, and acts as a mere transmitter
of trunk-line messages.

Cerebellum .—All impulses arriving by the inferior or superior
peduncles pass direct to the cerebellar cortex, the fibres ending
round the Purkinje cells. Here the whole body appears to be
serially represented. Probably not all sensations reaching the
cerebellum are finally lost. The co-ordinated results of some reach
the thalamus, and even the cerebral cortex, eventually raising conscious
sensations. Cerebellopetal impulses are largely received from the
frontal, parietal, and especially the temporal region through the
homolateral formatio reticularis, and so across by the middle peduncle
reach the contralateral cerebellar cortex. Many also come from the
semicircular canals through Deiter’s nucleus.

Cerebellofugal impulses pass from the central nuclei, especially the
dentate. Those in the superior peduncle reach the contralateral red
nucleus and thence the lateral thalamic nuclei; a small number pass to
the frontal, parietal, and occipital cortex by relays through the contra¬
lateral formatio reticularis, crus and internal capsule. The middle
nucleus gives crossed and uncrossed fibres to Deiter’s, the vestibular
and most sensory bulbar nuclei.

Optic thalamus .—The thalamus is the end station of the fillet and
superior cerebellar peduncle. In its essential nuclei sensory impulses
once more undergo regrouping. Those which underlie the more
primitive instincts, and, at the same time, influence the affective tone,
are dealt with on the spot. These are mostly protective and are such
as give rise to pain, but some—such as sexual feelings—produce an
opposite effect. The class of stimuli which are passed on to the
pallium is made up of such as involve discrimination, localisation,
postural recognition and comparisons of intensity—those, in fact, which
demand judgment, which is mnemonic comparison of former percepts.
It seems plain that impressions of all kinds are liable to affect
the cortex when they depart to any extent from a certain normal
mean ; thus excess of cold and heat may be interpreted as pain. I
cannot quite gather whether Head implies that if all connection were
severed between the pallium and an intact thalamus pain would still be
felt. Manifestly such a condition, either experimental or pathological,
would be most difficult to bring about. It seems to me that, just as in
hypertonicity the pyramidal tracts must not be wholly destroyed, so to
permit consciousness of pain or excessive temperatures the thalamo¬
cortical paths must be partially preserved. Normally it is plain that the
cortex limits thalamic activity, but I am not prepared at present to
believe that consciousness of any kind is possible apart from the
cerebral cortex. A profound loss of cortical function is seen in
advanced dementia, and here impressions of pain are difficult to evoke,
while the affective elements of sensation are entirely lost. It may be
objected that thalamic atrophy is also present, but this is unlikely, for
there is no cerebellar or bulbar defect. On the other hand, in low-
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grade idiots there is a low emotional threshold, resulting in whines
when cold or hungry, or struggles when moved. Pagano’s experiments,
however, seem to support Head’s contention. In Korsakoff’s syndrome,
where there is interruption at both extremes of the anatomical path
and the discriminative elements of sensation are lost, we find the
combination of intense deformative reaction to pain with the exalted
feeling-tone.

The thalamus consists essentially of two distinct parts—an outer,
comprising the lateral nucleus, which receives the fillet and cerebellar
afferent fibres and sends out a very complex radiation to all parts of the
pallium ; and an inner, which includes the anterior and middle nuclei
and is anatomically associated with the nucleus caudatus and putamen.
The corticipetal fibres pass especially to the postcentral lobule, but also
to the precentral. Few go to the frontal pole, and some cross contra-
laterally in the corpus callosum (Turner and Ferrier). On the other
hand Sachs finds that by far the largest number of corticipetal fibres go
to the precentral gyrus and are mostly of medium size; those to the
postcentral are fine, and very few are of medium size. The thalamo¬
cortical fibres to the Rolandic area are arranged dorso-ventrally. In all
regions of distribution the fibres between lateral thalamic nucleus and
pallium are both thalamocortical and corticothalamic. Many go to the
temporal and occipital regions. Some palliotectal fibres may run
through the thalamus without connections with its cells, but the system
of corticothalamic fibres is very complete, and is especially developed
from the temporal and occipital regions.

Corpus striatum .—The striate body consists of two distinct parts,
the caudate nucleus and putamen constituting the neostriatum, the
globus pallidus the paleostriatum. The latter is found in fishes as the
basal nucleus, the former is first found in reptiles, and is well developed
in birds. It is likely, therefore, that in man the striate system has, as a
functional complex, commenced to regress. The central connections
are entirely through the thalamus, none are direct; bundles of fibres
pass from the lateral nucleus of that body to the small cells of caudate
nucleus and putamen, then to the large cells, especially of globus
pallidus, by intercalary neurones, thence by the ansa reticularis system
to nucleus ruber, nucleus hypothalamicus and locus niger. Some fibres
may run from the globus pallidus to thalamus.

The Nature of an Emotion.

Ever since attention was drawn by Roussy to the existence of a
“ syndrome thalamique ” there had been a fairly general assumption
that the thalamus had an important function in modifying sensory
percepts; we gather evidence of this from the work of Nothnagel,
Dana, Mme. Vogt and others. But it was left to Head to examine and
codify the nature of thalamic sensations, and more especially to show
that partial interruption of the thalamocortical path had a profound
influence in releasing sensations registered in the thalamus from the
inhibitory effects of cortical activity. This view is now accepted by all,
and needs little further comment. Normally all sensations reaching

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the thalamus are subjected to minute analysis in the cortex, and allowed
or censored after judgment passed. In certain diseased conditions
either the connecting path is impaired or the cerebral cortex is unfit to
function, and the sensation then rises to the dignity of an emotion, a
condition which applies more particularly to such as are endowed with
an unpleasant feeling-tone, for these are the primitive animal’s first line
of defence against danger. If the interruption of the connecting paths
be complete or the cortical neurones be wholly thrown out of action no
sensations reach them, and complete anaesthesia, with total loss of
feeling-tone and emotion, results.

It will be desirable to avoid a too close psychological differentiation
between sensations, percepts and affection, for it is evident that in a
matter so complicated as a mental process a simple sensation is an
impossibility. We may, therefore, for present purposes, look upon an
emotion as a temporary flood in a stream of feeling-tones, a sudden
spate which, under normal circumstances, soon dies away. These
emotions are pure reflexes, they have reached the thalamus in countless
myriads certainly since vorticella first became endowed with a peri¬
stome and so developed its primitive orientative and nutrio-procreative
responses, for the early brain was in its nature hippocampo-thalamic.
The lower mammals, but especially birds, are, as Stoddart points out,
much more under the control of the emotions and their crystallised
resultants, the instincts, than is man. Every breeder of high-fertility
fowls knows that the visit of a stranger to the pens lessens the egg yield
for several days afterwards. The defence cries of animals are an
interesting study on the emotional side, although not strictly germane
to the present subject. Gregarious animals whose main defence is the
“ mobbing ” instinct, such as dogs and most birds, make as much
noise as possible when disturbed; solitary animals and those gregarious
animals whose main defence is flight, keep silent until the last moment
of supreme danger ; hence the peculiar poignancy in the scream of the
stricken horse or the squeal of the dying rabbit. These ancestral
reflexes are so strongly impressed that they persist even in states of
unconsciousness.

We have seen that the great sympathetic function is to warn against
danger, and the great autonomic function is quiet construction. But
there is a much older element, the influence of the hormones. This is
so built up into the activities of the two parts of the involuntary system
that the three together form the tripod upon which the animal organism
functions. A part of the hormone system is the action of enzymes, so
that these activate and interactivate among themselves in bewildering
but specific nicety, It is evident that the nervous influence is an after¬
growth, the result of which was first to accelerate, then to control. It
would compose a simple and attractive picture if we could conclude

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that the sympathetic function was unpleasant and defensive, that the
autonomic was pleasant and assimilative. But, unfortunately, the
matter cannot be so easily disposed of. There are some emotions,
such as fear, which are comparatively simple; others, such as anger,
which are very complex. Yet anger always arises out of fear, pugnacity
out of panic. Anger is at first unpleasant, and only assumes a pleasant
feeling-tone when it reaches a sublime disregard for personal safety, as
so often seen in epileptics and moral imbeciles. Again, the sexual
reflex in man is instantly dominated by anxiety, but this is not so in all
animals. In the frog the sexual reflex is prepotent, and it is said that
the male may remain for three weeks or more in the “ clasp posture,"
utterly regardless of hunger, pain or cold. I have seeu three males so
clinging to one female for many hours, and the only successful
inhibitor of the postural reflex was continued immersion. Even in the
dog the comparative prepotency of the sexual reflex may be seen. He
may die of pneumonia if someone throws a jug of water over him on
a winter’s night, but he refuses to budge from the desired door-step.
Yet the innervation of the sexual organs differs little in the frog, the dog,
and man. It is evident that both the autonomic and sympathetic
systems partake in the physiology of every emotion, but the relative
importance of their roles varies from time to time.

All feeling-tones do not eventuate in emotion, and, as Head says,
the less the projection and the greater the association the more is a
percept divorced from feeling-tone. All defensive emotions are not
tornados—they may develop slowly and last for weeks or months;
such a condition constitutes a state of depression. It would appear
that in melancholia there is a chronic hyperadrenalism, and although
degenerative changes have been described in these glands in various
mental disorders it is generally the cortex which is referred to, with
whose activities we are not now concerned. And the choice ol
involutionary melancholia as the subject of this address was largely
guided by the possibility of eliminating the positive influence of the
thymus, thyroid and ovaries, which in presenility are more or less
atrophic. As to the pituitary, we know too little of its internal
influence in later life to make it worth attempting to weigh it up,
and in the kidney we have a fairly constant factor, for most of such
patients suffer from renal cirrhosis, although only a small percentage
become depressed. We are, therefore, in a position to make an
attempt to trace the anatomical mechanism used by the passage of an
emotion. I agree with Stoddart, except as regards the thalamocortical
path:

(i) A percept arrives at the outer part of the thalamus from one of
the cortical centres. The commonest projections are visual or auditory,
and it must be noted that a direct thalamic impulse will not do ;

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such a sensation must be first elaborated in psychical association
■centres. A strong peripheral excitation may be realised as pain, but
never, in the first instance, as an emotion.

(2) At the same time the inhibitory paths to the skeletal muscles
by way of the pyramidal tracts remain closed.

(3) The impulses are codified in the essential thalamic ganglia and
some pass from the inner part of that body to caudate nucleus or
putamen.

(4) Translated into a motor impulse the path leads from the globus
pallidus viA the pes anserina and red nucleus down by the rubro-spinal
tract.

(5) From the anterior cornual cells (except in the case of inhibitory
impulses to blood-vessels, which are antidromic from the posterior
horn) the excitation is distributed either by the “final common path”
(Sherrington) or by the paleokinetic fibres (Ramsey Hunt) and to
the paravertebral ganglia of the sympathetic and the ganglia connected
with the bulbosacral outflow; thence to the secreting cells of glands,
and to the sarcoplasmic elements of voluntary and involuntary
muscle, the latter in skin, vessels, heart, lungs, glands and intestinal
walls. Here it produces its specific action, either motor, inhibitory or
secretory.

(6) The resultant is a complex of sensations which pass back to the
posterior roots, largely by protopathic or deep fibres and the sympa¬
thetic units to Lissauer’s tract and so into Clarke’s column.

(7) The upward cord path is complicated and uncertain. Some
impulses at least may travel by the ipsolateral posterior column, and,
after gradually crossing, by the contralateral spinothalamic tract. Others
probably go to the cerebellar cortex in the lateral columns by the
ipsolateral dorsal spinocerebellar and contralateral ventral spino¬
cerebellar tracts.

(8) From the dentate or other internal cerebellar nucleus the impulses
pass to the pontine and red nuclei via the middle and superior cere¬
bellar peduncles, and then go to reinforce, in the fillet, any which may
have travelled direct, the latter entering the inferior part of the lateral
nucleus of thalamus, the former being disposed to the superior part.

(9) After integration in the thalamus some of the impulses travel to
the cerebrum by the thalamocortical radiation, and are realised in
consciousness.

The path of an emotion takes a ludicrously long time to describe,
but not proportionately longer, if we compare the relative speeds of
speech and thought, than it takes to materialise; for it is doubtful if
any emotion has a shorter latent period than 75 sec., much longer than
the reaction period of an ordinary reflex act. To my mind this is the
strongest proof of what is now recognised, that the motor-sensory

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complex causes the emotion, not the emotion the motor-sensory complex.
In practice no method of measuring the reaction time of an emotion
can be satisfactory. A simple cortical reflex without discrimination
takes ’15 sec., with discrimination '3 sec. The galvanometer needle in
the case of an emotion is deflected after 3 seconds, a large part of this
delay being due to the time taken for sweat to be secreted. We
realise introspectively when we duck the head from a flying object that
the muscle reflex is over long before the cardiac acceleration is
perceived. The latent period of an emotion, unlike that of an ordinary-
cortical reflex, cannot be shortened by attention, for it is thereby
destroyed, nor by expectation, for the emotion has already been
created.

The State of Depression.

At this point it will be helpful to review some of the signs which we
find present in states of depression, and compare them with those we
have already found to be characteristic of the depressive emotion. The
heart action tends to be weak, the pulse rather frequent, but quick and
soft. The systolic blood-pressure in the brachial artery in the erect
posture is inclined to be low. This is in opposition to the findings of
Craig and others, but we have taken the readings in some hundreds of
cases, both soldiers with the anxiety neurosis and depressed persons
of all ages and both sexes in hospital and consulting practice. In the few
cases in which the blood-pressure was materially raised there was ample
evidence—such as enlarged heart or albuminuria—of chronic Bright.
But in melancholia the distribution of the blood is unequal, the skin is
poorly supplied, as are also the viscera, the urine being diminished.
Capillary dilatation is not seen except in some cataleptic cases or those
of anergic stupor, which we are not now considering. It should be
noted that adrenalin acts on the arterioles, histamine on the capillaries,
where there is no evidence of the existence of vasomotor nerves. The
capillary flow in the secretory glands is small, but the capsular tissue is
contracted, so that they feel hard. There is sometimes slight sweating,
so that the electrical resistance of the skin is lowered, but in general
the secretions are diminished, especially the intestinal, a furred tongue
and constipation being the rule. Peristalsis is diminished and the
sphincters are contracted, hence hydrochloric acid tends to collect in
the stomach, and the normal hormonic train of digestion is interfered
with ; anorexia is marked. As to the lacrymal glands, “ misery is dry¬
eyed.” Accommodation is impaired and the pupils are large ; in many
depressed neurasthenics lateral pseudonystagmus appears. The skin
is muddy and sallow, pigmented in the flexures, pointing to partial
haemolysis. The “voluntary” muscles act poorly, due to at least three
causes—weakness of cortical impulses, imperfect removal of fatigue

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products, and deficiency of muscle catalysts. On the emotional side
there is increased reaction to unpleasant stimuli, although the threshold
is raised ; reflex postures appear, and in anxiety neuroses rhythmical
tremors, pointing to loss of cortical control over the thalamo-rubro-strial
system.

The foregoing signs make it evident that the state of depression is
nothing more than a persisting sympatheticotonus, but when we have
to analyse the anatomical paths two fresh complexes appear—the one
is enterostasis, the other the unconscious memory. I believe that
enterostasis, whether produced mechanically or by enterospasm, is a
necessary precedent to a state of depression. The frequency of visceral
sensations, feelings of weight and oppression, or actual delusions, makes
it inherently probable, and when we find it present clinically all doubt
is removed. Naturally the enterospasm is not constant, any more than
is anxiety, but the greater the anxiety the more likely is one to find it.
When we have obtained a detailed history of onset in a case we
invariably find that the depression was a secondary mental state and
was preceded by some slight visceral disturbance. If the mental
causative factor be large the visceral may be small, and vice versa, for
many normal persons are living little over the border-line between
effective bacteriolysis and toxaemia. Commonly a history like this
appears : A young girl has a love disappointment which has worried
her for some weeks or months. A day or two after a menstrual period
she begins to think her relatives are different towards her ; next the
people in the street look at her strangely, and in a few days depression
comes on. Or in an involutionary case a relative will tell one, “ Father’s
memory began to fail a few years ago, but he did not talk strangely
until a month ago; three days ago he tried to cut his throat.” The
father is found to have advanced enterostasis. No one constantly
living with cases of mental disorder can fail to believe in bacterial
toxaemia. I am aware that it is maintained that B. coli are never found
in the blood except post-mortem ; this does not alter the probability that
the chemical products of bacteriolysis are there. Probably also sub¬
infection occurs, and is one of the causes of cortical degeneration, in
which case the bacilli would naturally not be found. The colon
infection need not be primary ; it may follow a deteriorated blood state,
biochemically produced, as in alcohol, or prolonged lactation, or
resulting from some other bacterial invasion, as in the puerperium, or
rheumatism, or influenza, or tuberculosis, or pyorrhoea alveolaris. I
believe there is a hereditary tendency to enterospasm, that it is in fact
one of the phenomena of the neurotic inheritance; so far, therefore,
the contention of Eppinger and Hess that a sympathicotonic and a
vagotonic temperament exist appears to be justified, and here again we
see the usual vicious circle, for the enterospasm leads to bacteriolytic

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absorption, and this to defective cerebral control, which brings on a
sympatheticotonus with increased enterospasm, and the result is
depression.

As to the unconscious memory, it is no use denying its existence, as
some would prefer, for it actually exists; the censure can be removed
by psychotherapeutic methods, and when the conflict is resolved more
rational mental complexes can be built up. In cases before the presenile
period the unconscious memory is a most potent factor in weakening
the normal psychical control cf the cortex over the thalamus, but to
erect it as the sole fence that needs to be climbed, and to claim
that physical measures are useless to cure, is as futile as to maintain the
opposite opinion, for even such an elusive element as the unconscious
memory is partly capable of definition in terms of ordinary physiology.

Regarding the paths used in states of depression there is probably
not much difference from those of the depressive emotion. Entero-
stasis will produce afferent stimuli which reach the psychical centres
and may at times be fabricated into delusions. The unconscious
memory will act in association centres through projection centres, not
directly. The presence of the downcast expression and reflex postures
indicate vestibular reinforcement through extrapyramidal paths, the
vestibulospinal and pontospinal tracts, and we can often do real good
in our treatment by encouraging the patient voluntarily to inhibit these
extrapyramidal reflexes by continuous attention.

The phenomena observed in states of depression are, therefore,
nothing other than a condition of persistent sympatheticotonus, a
defensive reaction chiefly of the infracortical nervous system, involving
hyperadrenalism, hyperglycaemia, the adducted posture, enterospasm
and defective cortical inhibition. These basic facts seem to be
established, for their presence in states of fear has been fully proved
by the observations of many workers, and a state of depression is one
of persistent fear.

The Exaltive Emotion.

The nature of percepts devoid of feeling-tone does not now concern
us, but in order to search for any evidence of some fundamental
difference between the conditions which pertain to the depressive and
exaltive emotions respectively it will be necessary to say something
about the latter. Now this subject is very much more difficult than
the one we have been considering, for the original object is no longer
defence against an enemy, a matter kept perpetually before every
animal throughout its whole life, but is merely an occasional episode,
and one which has therefore tended to be far less sterotyped. When
one looks round over the fields of physiology and pathology only two
examples can be found which fulfil the objects of our search ; the one,

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the exaltive emotion, is the sexual reflex; the other, the state of exalta¬
tion, is the early preparalytic stage of paralytic dementia. There may
be better examples ; if so I cannot find them.

The innervation of the sexual organs was studied by Langley and
Anderson, and their dissections of the parts are a model of patience and
minute care. The internal organs, uterus, vagina, prostate, vasa
deferentia and vesiculae seminales, have a sympathetic supply only,
viz., through the hypogastric nerves. The external organs, penis,
clitoris, erector penis and sphincter vaginae, have a double supply, from
the sympathetic through the pudics and hypogastrics, from the auto¬
nomic through the pelvic nerves (nervi erigentes). Electrical stimula¬
tion of the hypogastric produces a wave of contraction in the vagina
passing into tonic spasm, with blanching of the walls from vasomotor
constriction, while the vasa deferentia, vesiculae seminales, and involun¬
tary muscle of the prostate are strongly contracted, emission of semen
and prostatic fluid occurring. Stimulation of the pelvic nerves produces
active dilatation of the muscular tissue in the walls of the venous
sinuses of penis or clitoris, causing strong erection, with inhibition of
vaginal movement and relaxation of the sphincter. It would therefore
appear at first sight that we have here a powerful autonomic wave,
which overcomes and inhibits the sympathetic. But in the sexual act
the progress of events is different, for we have rhythmical peristaltic
waves of contraction and relaxation in vagina, vesiculae seminales and
vasa deferentia, and finally the same phenomenon spreads to the
detrusor urinae and sphincter vaginae, while the inhibitory dilatation of
penis and clitoris is tonic, as is also the spasm of the vesical and anal
sphincters, the dilatation an autonomic, the spasm a sympathetic
mechanism. Not only so, but the uterus becomes turgid and rises in
the pelvis and the fimbriae of the Fallopian tubes open widely, both
apparently from sympathetic inhibition. It is therefore evident that
in the sexual reflex we find a nice adjustment of autonomic and
sympathetic influence regulated in strict accordance with sensory
afferent stimuli. The pain on pressure after discharge is a strictly
protopathic function of the innervation of glans penis and clitoris
whose mucous membrane is derived from the endoderm of the hind-gut,
while the skin of penis and foreskin, endowed with epicritic
functions, is derived from the somatic ectoderm. The centre for the
sexual reflex is in the lumbar cord, but the feeling-tone is a function of
the thalamus. Head quotes two cases suffering from thalamic lesions
who showed the exaltive feeling-tone. In one a woman found exquisite
pleasure in the apposition to the chest on the affected side of a hot-
water bottle which on the sound side felt only comfortably warm. In
the other a man confessed to erotic feelings on the affected side, “ I
crave to place my (right) hand on the soft skin of a woman.” Here we

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find the creation of an erogenous area by disease, similar to those which
occur normally on the mammae, or, in fact, on any part of the body.
It is evident that the thalamus is the centre which presides alike over
the depressive and exaltive feeling-tones and emotions. The sexual
reflex differs from the depressive emotion in that it is accompanied by
a free flow of arterial blood through arteries and veins, the heart is
beating powerfully and the breathing is deep ; oxidation of the blood is
at its maximum. In his treatise on “The Automatic Bladder” in
severe gunshot wounds of cord, Head gives several instances of the
delicate adjustment between the functions of the autonomic and the
sympathetic nervous systems. The patients, who were completely
paralysed and devoid of sensation below the level of the injury, exhibited
the mass reflex. When the bladder was full hyperidrosis occurred,
and facilitation of contraction by peripheral stimulation was possible.
In some cases slight physiological connection with the brain still
existed because the cord was not completely destroyed. In such
cases the patient was ignorant of the catheter manipulations, but knew
when the bladder was full by the sweating which occurred. If pinching
the glans penis or other form of irritation produced erection no sweating
appeared. One such patient experienced the “ thrill ” or “ shiver” of
a pleasant nature when the distension was relieved, which is often
normally felt. The contrast between the sympathetically induced
hyperidrosis and the autonomically induced erection of penis or nervous
thrill, so analogous to the phenomena associated with sexual excitement
in the normal individual, well illustrates the reciprocal integration
between the two divisions of the involuntary nervous system.

In general paralysis the neuronic degeneration is so universal, and
the disorganisation of the blood state so marked, that I desire to say
as little as possible about it, but I draw attention to the facts with
which we are all familiar, that in the early stage of exaltation we have
a free flow of highly oxygenated blood through brain and body, as
evidenced by the full heart-beat, the deep respiration, the insanely
erect attitude, the abducted posture, the free gait, the muscular activity,
the bright eye and the activity of the secretions. Whether all these
are a reflex response to the toxaemia does not concern us. My thesis
is that in the exaltive emotion there is hyperoxamiia, in the depressive
anoxaemia ; it follows that the essential determinant of the state of
depression is an anoxaemia.

Atheroma and Anoxaemia.

I put forward the theory that in states of depression there is a
condition of general anoxaemia due to the failure of the haemocytes to
convey sufficient oxygen to the tissues; but when direct proof is asked
for I may at once say that it is not forthcoming. I have never been

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one of those who believe that the acute psychoses are primary results
of cerebral disorganisation, or that the clinical distinction between the
various types was any other than a more or less accidental occurrence,
although doubtless produced by a special presentation of disordered
metabolism. But without losing sight of Clifford Allbutt’s dictum,
“The paths of science are paved with the broken stones of finalist
hypotheses,” it may still be justifiable to give some indications of
probability, and in this connection the study of atheroma may help.

Atheroma is normal to senility, and is an index of involution, but it
occurs prematurely in practically every case of involutionary melancholia.
It is also one of the most constant factors in syphilis, a disease in
which there is no reason to premise a failure of tissue oxidation,
although McDonagh maintains that there is. Oberndorfer found
aortitis in 7 per cent, of 1436 adult post-mortems , Grober in 4 per cent.
of 6000. In 256 undoubted syphilitics Marchand found the percentage
to be 82, Dencke 88 - 6, Oberndorfer 67, and Citron in congenital cases
also 67. In our last 288 male and 284 female post-mortems , total 572,
on persons under 50 years of age, macroscopic arteritis was found
present in 52'o8 per cent, of males and 30'28 per cent, of females; in
general paralytics in 79 per cent, of males and 92 per cent, of females ; in
epileptics 3o'55 per cent, of males and I3‘33 per cent, of females.

Atheroma is the result of an abnormal amount of ionisable calcium
in the blood-stream, due to either increased intake or excessive tissue
output, and Percy Lewis found that it was not commoner in limestone
districts or among milk drinkers. Nor can it be produced by feeding
animals with excess of the inorganic calcium salts. There is a con¬
siderable amount of evidence linking up intestinal inaction and
bacterial invasion with its development. Thus Simnitzky found that
it was apt to occur after most of the specific fevers, and especially to
be produced by the pneumococcus ; McCarrison found that in pigeons
and guinea-pigs on a beri-beri diet the feeding of bacterial material
produced enterostasis and neuromuscular intestinal impairment, facili¬
tating bacterial invasion. Manou£lian produced atheroma in 25 out of
33 rabbits by the inoculation of faecal material. Robertson recognises
five classes of toxaemias, of which three are endogenous. It has long
been recognised that indicanuria was an index of increased intestinal
bacteriolysis, and Mackenzie Wallis, Townsend and others found an
increased excretion of potassium phenylsulphate and indoxylsulphate
in melancholia and believe that both aerobes and anaerobes favour
proteolysis. Metchnikoff thought that anaerobes especially produced
toxaemia. Mellanby and Twort believe that atheroma is not caused by
these bodies, but by the decarboxylation of aminoacids by bacteria,
and that these creatin-splitting organisms are destroyed in the liver.
D’Abundo and Agnostini were of opinion that intestinal intoxication

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was not the primary but the secondary result of bacterial invasion, the
primary being mental worry or shock. Pellagrini found atheroma
common among prisoners of war, and attributed it to mental causes.
Goodall obtained indifferent results when searching for organisms in
the blood, and Ceni found various bacteria only just before death, and
considered such invasions to be mostly post-mortem. But these results
are not surprising, for it is not so much the bacteria as their chemical
toxins which are supposed to be absorbed. The connection between
pyorrhoea and the development of chronic rheumatism, osteoarthritis
and fibrositis is universally admitted.

The calcium in atheromatous patches is associated with cell fats and
lipoids. Substances which diminish surface tension tend to accumulate
at the periphery of body cells, and so the plasmatic membrane is largely
composed of lipoids. Attention was first drawn to the importance of
these bodies in cell metabolism by the work of Overton and Meyer-
They are soluble in ethers and alcohols, dissolving out with the fats.
The chief classes of lipoids recognised up to the present time are :

(1) Carbohydrate substances based on cholesterol, an unsaturated
monohydric alcohol built up of five reduced benzene rings with an
open chain doubly linked at the end. Cholesterol tends to prevent
bacteriolysis, haemolysis and the action of poisons.

(2) Glucosides, containing N but no P, two of which, phrenosin
and kerasin, called cerebrosides, have been isolated from nerve matter.
They yield on decomposition a monoaminohydroxy alcohol, a fatty acid
and galactose.

(3) Phosphatides, containing both N and P, the best known of which
are the lecithins, which yield glycerophosphoric acid, two fatty acid
radicles and cholin, an ammonium-like base, and the kephalins, where
hydroxylethylamine replaces cholin. Lecithin favours bacteriolysis,
haemolysis, and the action of poisons. Another phosphatide, sphingo¬
myelin, contains no glycerol.

(4) Sulphur lipoids. With these are associated water-soluble organic
substances, nucleoproteins, globulins and inorganic substances,
especially calcium.

The normal processes of metabolism occur through the agency of
specific enzymes and antenzymes, bodies of a protein-like nature.
These processes are analogous, but not similar, to those of bacteriolysis
and haemolysis. There is reason to suppose that the water-soluble
vitamines are of a like nature, but that the fat-soluble vitamine A is
lipoid in construction. In the anabolism and katabolism of the
materials to be used for cell-building, no organ takes a more important
part than the liver. It receives, for example, the bacteriolytic products
from the intestine in addition to the digested food materials. The
aminoacids are in the liver possibly built up into proteoses, and then
combine with non-specific complement, forming bodies of a globulin¬
like nature which possess a larger molecule. It would appear that the

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two most important results of excessive bacterial action in the intestine,
especially of the anaerobes, are increased production of ammonia and
decarboxylation of aminoacids. The former is rendered more effective
by the inhibition of the growth of the lactic acid groups, and the latter
releases toxic pressor and depressor bases. The combined effect is
lowering of the hydrogen-ion content of the serum, and as this must be
restored at all costs or else wide-spread cytolysis and haemolysis, with
somatic death, would quickly ensue, a severe call is made on the sodium
bicarbonate and sodium phosphate “ buffers,” and carbonic acid is
obtained from the fatty acids of the lipoid-globulin complexes. This
reaction sets free proteolytic and lipolytic enzymes which disturb
especially the delicate balance between the lecithins and cholesterols,
giving rise to the disintegration products which are found in the blood¬
stream. If fat destruction reaches an extreme degree all the free C 0 2 is
breathed out in the effort to secure oxygen, and the state of “ acidosis ”
results, with formation of B-oxybutyric and acetoacetic acids. The
body fixes its ammonia and alkalises its cells, so that the titration value
of the “ alkaline reserve ” is lowered. Moore, Galleotti, Haldane,
Priestly and others have shown that alkalinity of the blood is the
predominating factor in shock and that the condition is one of
anoxaemia. My colleague at Stafford, Dr. B. H. Shaw, working both
on the psychoses and on the delirium of malaria, finds acidosis
especially associated with states of confusion, and attributes to it some
cases of melancholia. At Cheddleton we have not found acetonuria in
states of depression unless confusion was marked, as in melancholia
attonita or post-convulsive epileptic automatism. The association of
acidosis with anoxsemia is seen in the air-hunger of diabetic coma.

There is evidence that liberation of cell lipoids is concerned in the
production of atheroma. Thus, Loeb, Wacker and Huack produced it
in animals by feeding cholesterin over long periods, and Elliott showed
that the adrenal lipoids greatly increased under similar conditions.
Faber proved the presence of lime and fatty granules in presenile
arteries where no evident atheroma had developed, and in fact
anisotropic fats have long been recognised in atheromatous patches.
Blair Bell showed that removal of the adrenals from rabbits increased
the calcium excretion from seven to sixteen times, and that osteomalacia
developed. He also showed that the internal secretion of ovary and
thyroid depleted the blood and tissues of calcium, and that the adrenals
had an antagonistic action. In ovulation the cells were observed
carrying the lime granules to the surface. In hens in full lay the
blood-calcium is high, and drops suddenly a few hours after an egg is
laid. Some years ago I found that the vitamine fat-soluble A helped to
ionise calcium ; if hens were given 7 c.c. of milk daily with slaked lime
the shells improved in thickness, but this did not occur when the lime

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was given alone. It was not caused by the calcium caseinate of the
milk, for a hen excretes more lime in a day than she could thus ingest
in a week. This observation also throws light on the softness of the
bones and the liability to strains in institution pigs, who are largely fed
on material which is loaded with salt and has been thoroughly boiled.
The production of mucous colitis by calcium stearates, which
accumulate in the intestine in defective stasis, the observations of the
Mellanbys on the development of puppies’ teeth, and the work of
Harriette Chick on rickets and osteomalacia in Vienna, are all
illustrative of the intimate connection between lime and cell lipoids,
and incidentally illustrate the known fact that the B. suipesii/er easily
attacks institution pigs. Mott’s observations on the lipoids of the
testicle connect up Blair Bell’s work on the importance of calcium in
the building of the protein molecule. Mott found that the lipoids of
the testicle were exhausted in dementia praecox, but not in general
paralysis nor by microbial intoxication, but Elliott found that those of
the adrenal cortex rapidly disappeared under the latter conditions, and
that the pneumococcus was the most toxic agent, the one in fact with
which, among the acute specifics, anoxaemia is most prominent.
Depletion did not occur in hyperpyrexia but did occur in severe
haemorrhage.

Liberation of cell lipoids and the development of atheroma
occur under anoxaemic conditions. Hoppe Seyler showed that
atheroma was common in states of defective oxidation. Meyer
showed that oxalic acid poisoning was the result of cell anoxaemia, and
Januschke proved that calcium was an antidote. Calcium tends to he
deposited in parts where oxygen metabolism is low and the flow of
lymph stagnant. Thus, Moore points out that bone is in this way
developed from extravascular cartilage, that in the bones of old people
calcium is in excess, and that it is deposited in the distal joints, the
hands and toes, in gout, also in tuberculous foci, and in the large
arteries if the vasa vasorum are stretched by hyperpiesis. He notes
that it is associated with incomplete oxidation of proteins, and occurs
as the very insoluble salts, urate, oxalate and phosphate. Klotz
believes atheroma occurs as follows : The cholesterin free in the
blood dissolves in the fatty acids, and then is deposited in the tissues
by crystallisation, leaving the fatty acid radicles to combine with
sodium, potassium and calcium. The soluble soaps disappear, and
calcium, from its affinity for divalent acids and the tendency in a
double decomposition for an insoluble salt to form if chemically
possible, is deposited as carbonate, the phospho«us being excreted as
soluble phosphates. Clifford Allbutt recognised that atheroma and
arteriosclerosis occurred in presenile cases without hyperpiesis, a fa ct
which alienists have always known. He first called the cases

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involutionary and then adopted the less convenient term decrescent.
He attributes the cause to a reduction of the quantity of blood without
increase of blood-pressure, hence less oxidation. Bullock and
Cramer found that calcium was necessary to determine the toxicity of
the B. Welchii of gas gangrene and considered that it disturbed The
relationship of the cell-protectives, that is, the lipoids.

It is acknowledged that tissue respiration depends largely on the
action of oxidative enzymes. Kellaway found that want of oxygen, but
not increase of carbonic acid, stimulated the production of adrenalin
and hyperglyaemia, and that this occurred even after the splanchnics
were divided. Buchner showed that in anaerobes oxygen exchange still
went on. Bach and Chodat separated the oxidases into two classes,
the oxygenases which take up nascent oxygen and form tissue peroxides,
and the peroxidases which transfer these to oxidisable substances.
Batelli and Stern showed that minced tissues had large respiratory
powers, and Vernon demonstrated that the link between the oxidases
and the oxidisable substance depended on the balance between the
various cell lipoids, and that the respiratory capacity of tissues could
fail apart from injury to the oxidases. He showed that heat and
narcotics destroyed the oxidases by first unbalancing and then
destroying the lipoids. Moore, however, attributes cytolysis more to
the disturbance of the balance between the crystalloid and colloid
elements, and says that the stability or state of aggregation of a
colloidal suspension varies with the concentration of electrolytes in
common solution with it. McDonagh’s work on syphilis throws a good
deal of light on many of the mechanisms of cell metabolism. The
lipoid-globulin particles form the internal or disperse phase, the
phosphate and bicarbonate systems the external or continuous phase.
Oxygen is normally produced by the action of ferric hydroxide protein
upon hydrogen peroxide, hydrogen by the action of disulphide protein
upon hydroxyl, so that the oxidase-reducase system depends upon
hydrogen-ion and hydroxyl-ion balance, and this maintains the lipoid-
globulin particles in solution. The “middle piece” of the complement
in fixation reactions is the oxidase-reducase system of the internal
phase, the “end piece” is the hydrogen-ions and the hydroxyl-ions of
the external phase, and the whole complement represents the balance
between the two phases. But, whatever the manner in which these
mechanisms work, it is clear that in both atheroma and melancholia
there is in the blood-stream an undue amount of cholesterin, lecithin,
phosphates and calcium, and as these are products of tissue-cell
destruction there must be considerable loss of oxidative power. The
blood becomes hypotonic, and in melancholia we recognise partial
haemolysis from the pigmentation; haemolysis occurs in hypotonic
solutions, as seen in the stained spinal fluid in intraventricular

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haemorrhage. More ammonia becomes fixed and less appears in the
urine ; there is therefore a low carbonic acid tension and no hyperpnoea.
Haldane showed that carbonic acid increased the depth, want of
oxygen, the rapidity, of respiration ; in melancholia the breathing is
hufried but shallow. He also showed that in neurasthenic soldiers,
where the conditions of anxiety or depression are marked, the oxygen
chamber did much good and improved exercise tolerance, although here
the influence of suggestion must not be lost sight of. Thirty years ago
Bevan Lewis showed that in melancholia more than the other psychoses
not only was the haemocyte count diminished, but the percentage of
haemoglobin per haemocyte was lowered ; it may comfort the modern
iconoclast to know that he headed his chapter “ States of Depression.”
It is impossible to compare the acute anoxaemia of asphyxia, carboxyl
poisoning, and the effect of high altitudes with the slow, chronic
destruction of oxygen carriers in melancholia, but I understand that if
aviators neglect the initial mental confusion which these states produce,
and persist in altitude flights, great depression of spirits is one of the
symptoms which next appear. Haldane and Priestly showed that
acclimatisation to heights was rapid, and that the haemoglobin count
rose rapidly. But when an excess of bacterial toxines in the portal
circulation lessens the formation and accelerates the destruction of the
blood carriers, no such compensation can occur. This is why we see
in states of depression the low blood tension, with diminished quantity
of blood fluid, hypotonia, pigmentation, deficient urine with loss of
urea and gain of uric acid and urates, shallow breathing, and general
loss of muscular initiative. I have seen a case of fatal cut-throat where
less than a pint of blood escaped from the severed carotid.

But all the above evidence has little bearing on the actual cause of
the state of depression. This is, as we have seen, the sensory response
to a muscular or muscle-vascular tone. It cannot depend upon the
mere presence of hyperglycremia or hyperadrenalism, for in diabetes it
does not usually occur, although it is not uncommon towards the end,
when cell destruction is heralding acidosis and coma. Kozawa showed
that in diabetes the erythrocytes were increased. It is therefore possible
that the presence in the sarcolemma element of voluntary muscle of
unoxidised glycogen complexes may furnish the necessary afferent
stimulus to keep up the sympatheticotonus. The adrenalin outflow is
defensive, and there is some evidence that adrenalin acts as an oxidase.
Sajous found that it promoted oxidation in the protein element of the
leucocyte, and at Cheddleton we have been able temporarily to abolish
the state of depression by repeated large hypodermics of adrenalin, and
to substitute for it a state of exaltive excitement. Adrenalin is destroyed
in an hour or two, and no permanent good resulted ; when the adminis-
ration was stopped depression returned. But it cannot be for nothing

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that, with the gradual development of cerebral cortex in higher animals,
we also find an increasing integration of two tissues in the adrenals, the
cortex and medulla, derived from totally different sources and anatomi¬
cally separate in lower phylae. We are bound to ascribe it to a
chemiotaxis between the cortical lipoids and the medullary
adrenalin.

If depression depends upon an anoxaemia, can we do anything in the
way of treatment by increasing the oxygen intake? We have of late
been tentatively injecting hydrogen peroxide intravenously in normal
saline. The results are encouraging, but much work must be devoted
to the technique before such methods can form a part of routine treat¬
ment. At present somewhat alarming symptoms sometimes occur—
partial collapse, cyanosis and rigors. Until the cause of these has been
determined the results must be inconclusive, and probably acute oxida¬
tion of body cells with extensive hremolysis is too drastic, and cannot
be maintained for a sufficient period to do lasting good. In one case
three injections in one day induced a normal mental state for two days,
then followed by relapse. Here again the influence of suggestion must
be borne in mind.

The Posture in Melancholia.

In some states of depression, especially where the emotion is strongly
marked, a typical posture is seen, and is well described by Stoddart.
The head and trunk are inclined forwards, with slight flexion at hips,
knees and shoulders. The elbows are held rigidly to the side and flexed
to a right angle. The corners of the mouth are turned down and the
forehead wrinkled. The attitude is dependent upon a rigidity which
affects the large proximal joints most, called by Stoddart “ proximal
rigidity.” The voluntary trunk muscles are most affected, next the
shoulders and hips, the elbows and knees less so. Co-extensive with
the rigidity there exists slight voluntary loss of power over the affected
muscles. The superficial reflexes are diminished, with flexor hallux
response, the tendon jerks are increased but the excursion is small, the
reciprocating tone of the opposing muscles is low, clonus is absent.
This posture occurs in anergic and cataleptic stupor and in involu¬
tionary melancholia chiefly, and is of considerable interest to our thesis ;
it therefore demands a short summary of the views put forward to
account for muscle phenomena. I suppose few physiological questions
have raised more discussion than those concerning the nature of
tremors, spasms and tonicity.

The nerve current is probably molecular in character, not chemical.
Helmholz taught that the pitch of contracting muscle was 19^ vibra¬
tions per second, the first overtone of 39 v.p.s. being actually heard.
Horsley and Schafer showed that 8 to 10 undulations per second

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reached the muscles in the tetanus of epilepsy. Piper found that
50 twitches per second were required to produce tonus ; if fewer than
about 30 reach the muscle clonus occurs. This is well seen in the two
stages of the epileptic fit. Schafer considers that during contraction
the clear fluid flows from the ends to the middle of the sarcomere, but
McDougall considers this is merely an optical effect. It would appear
that the stimulus produces a difference in tension between the H-ions and
the OH-ions, which by increasing acidity promotes energy production.
It is admitted that this energy is ultimately derived from glucose, and
from this glycogen-precursor lactic acid is produced, which Hopkins
and Fletcher showed to be afterwards removed by oxygen, with the
production of C 0 3 . The lactic acid is diffused away from the point
stimulated, but if a second stimulus arrives before this can happen a
summation occurs, so that ultimately a succession of subminimal stimuli
results in contraction. The higher the local Ph the faster will the
lactic acid diffuse away. If the Ph is too far removed on the acid side
of the optimum the refractory period will occur. Thus Mines accounts
for these two phenomena.

Boeke showed that fine nerve filaments were distributed from the
anterior horn cell to the muscle plate, and neurofibrils leave this to run
parallel to the striped muscle fibre, ending in the anisotropic disc. The
sympathetic fibres from the grey rami form an unmyelinated plexus on
the muscle fibre, the neurofibrils ending in the sarcoplasmic end-plate;
as a rule the two sets come from different cornual levels. Langelaan
believes that this difference of distribution accounts for tonus being
automatic, controlled by the sympathetic, and arising in a proprioceptive
arc; if the cortical influence prevails the twitch is dominant. Ranson
agrees that myotonia results from the sarcoplasmic connection, voluntary
movement from that of the sarcostyles. Charles Bolton showed that
there was no connection between the flexor tonus and atrophy in
myotonia atrophica, for the former was absent in the lower limbs in
cases where the latter was marked. Kleist thinks that for tonus there is
a cerebello-rubro-thalamo-frontal afferent path and a fronto-pontine-
cerebello-dentate-rubral efferent path. Ramsey Hunt believes that
cerebellar intention-tremor and ataxia are both forms of cerebellar
asynergia. He cites cases to show that in juvenile and senile chorea
there is a progressive degeneration of the large cells consecutively in
(a) globus pallidus, (b) putamen, ( c ) caudate; and that the signs are
(1) in early cases tremor, often coarse, not intentional, with emotional
rise, (2) in late cases slow movements, rigidity, festinant gait and
prosthotonic posture. The paralysis now involves both associated and
automatic movements, and at last all the voluntary muscles are rigid.
In Huntingdon’s chorea, on the other hand, the large motor type of cell
is preserved, but the small, neostriatal cells are destroyed wholesale, and
the short, internuncial fibres degenerate. He connects the pallidal
mechanism with the sarcoplasmic element of muscle. Wilson describes
a familial degeneration of globus pallidus where involuntary tremors,
hypertonicity, contractions and emotional exaltation occurred. He says

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that for the production of either tremors or athetosis the pyramidal tracts
must be partially intact, and notes the frequency of athetosis after cerebral
lesions; he therefore infers that tremors may be due to impairment of the
lenticulo-rubro-spinal path, athetosis to impairment of the cerebello-
rubro-thalamo-cortical. Wilson and VValshe describe two cases of frontal
and prefrontal tumours with tonic innervation in which, after operative
removal, atonic hemiplegia remained. No sensory changes were
present.

Sherrington has thrown much light on muscular tone and posture.
He shows that the spinal cat will often stand, but that the decerebrate
cat always will; if the head is pressed down the forequarters sink and
the hindquarters rise, if the head is pressed up the opposite occurs. He
points out that Magnes and de Kleijn proved that this was due to
labyrinthine and deep neck nerve influence. He shows that standing
is a postural reflex, the muscles toned up to every position, and that
similar reflexes exist in the normal stomach, abdominal walls, bladder
and sphincters. Thus we see how, when the kidneys are actively
secreting, a small bladder distension causes discomfort, but if slow
secretion occurs a large amount of urine may be tolerated. If the
decerebrate animal be laid on its back vestibular reinforcement of tone
occurs. The position is not now postural but defensive. The spinal
reflex keeps the muscles toned up, but the centre for reflex standing is
behind the anterior limit of the mid-brain and in front of the posterior
end of the pons ; it is not in the cerebellum. Reflex tonus shows (1) a
low degree of tension, (2) great tonic endurance, (3) easy interruption
of postural contraction by inhibitory influences, (4) adjustment to
equality of tone in any position of lengthening or shortening. The
energy expended in maintaining posture is so small—stated by Parnas to
be -ruswts °f that expended by tetanised muscle—that the supposition has
been put forward that one kind of motor impulse sustains in the muscle
the hydrogel state, another produces the hydrosol, or that the resolution
of the hydrosol is brought about by indirect afferent impulses. This
brings us back to the theory of the tonic sarcoplasmic and the con¬
tractile sarcostyle elements, as developed by Botazzi, for in the case of
the voluntary mechanism the same muscles are used for both effects.

Walshe applies Sherrington’s findings concerning postural reflexes
and defensive acts to the signs found in spastic paralysis. He shows
that in the lower limbs the tonic extensor spasm is static, and the
reflexes represent the flexor or phasic type, which includes the so-called
“extensor” hallux response of Babinski. The pyramidal system
innervates the flexors and extensors, while the extrapyramidal system
innervates mainly the extensors. In pyramidal injuries both reflex
systems are released from control, and spastic extension appears. If
the extrapyramidal path also is interrupted the reflex activity of the
extensors is abolished, and may allow spastic flexion. The reflexes are
the result of the action of spinal centres, and are defensive; the
spasticity is due to the mid-brain centres, probably in the red nucleus,
and is postural. In the upper limbs spastic extension does not occur,
but spastic flexion. This is because in man the arms take no part in
the maintenance of the erect posture.

Ramsey Hunt extends Boeke’s and Langelaan’s findings, and would

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have it that there are two complete muscular systems—the paleokinetic
with its fibrils extended to the sarcoplasmic elements, its fine non-
medullated fibres running right up the cord, and its motor centre in the
striate body ; and the neokinetic, or ordinary corticopyramidal, whose
larger white fibrils extend to the sarcostyles. The former regulates the
static and postural forms of mobility, the latter the kinetic. He quotes
evidence for the existence of a paleocerebellum and a neocerebellum,
and also draws attention to the distinction between the spasticity of
cortical lesions and the rigidity of striospinal, to the different form
assumed by the reflexes, and to the fact that the neokinetic affects
terminal joints and the paleokinetic proximal. There is a different
regeneration period for the two systems in the peripheral nerves,
analogous to the difference between protopathic and epicritic on the
sensory side. Head states that cases of postcentral injury may show
hypotonia provided the pyramidal tract is intact, and that underneath
the massive spasticity of cortical or subcortical injury hypotonia may
be found if both afferent and efferent mechanisms are disordered.
It is generally admitted that hypertonus requires a not completely
destroyed pyramidal system, for after the deep injury produced by the
removal of cortical tumours both hypertonus and its psychical reinforce¬
ment, “ intentional perseveration,” disappear. But in parietal gunshot
injuries without motor paralysis we occasionally come across cases
showing nutritional changes; the hand is delicate, the fingers tapering,
the skin smooth, the nails translucent and thin, the muscles small;
whether we call such a condition “ disuse atrophy,” or give it any other
name, it points to interference with the posterior root ganglion element
in sensation. Again, in very old hemiplegic cases, especially when the
dementia has become profound, spasticity disappears, and only fibrous
rigidity remains. This element in muscle belongs to the protopathic
side of sensation; also it is part of the function of the involuntary
nervous system, especially the sympathetic, i.e., the system w r hich deals
with vessel tone and the sarcoplasmic element in muscle, and which,
as seems probable, is represented in the cerebral cortex. Sometimes
loss of the sense of passive position and movement was in Head's cases
dissociated from hypotonus, although more commonly both disappeared
together. It follows, therefore, that in some part of their course the
paths run separate. The involuntary nervous system is centred in the
thalamus on the afferent side and the globus pallidus on the efferent,
.and the thalamocortical connections are mostly by way of the internal
capsule. I am not prepared to guess what the course of these
nutritional fibtes is. I once thought it possible that they might reach
the cortex along the central arteries, but this is unlikely—there is no
known instance, I believe, of pre-ganglionic fibres being so conveyed.

Putting together the above evidence in the light of Head’s work on
the functions of the thalamus it is not difficult to come to certain con¬
clusions. The functions of the involuntary nervous system are an
elaborate type of automatic movements necessary for the existence of
the animal, especially for its defence. For these reflex movements
consciousness is not necessary, but the elements of sensation elaborated
in the thalamus, which if produced into consciousness evoke certain

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specified feeling-tones, are necessary. This system is subordinated to
the cortex in higher animals, and in its turn controls the bulborubral
and cerebellar centres, which are responsible for postural tonus, and, of
course, the spinal centres, which control the lower organised defence
reflexes. In melancholia the cortical control is removed in part, and
the thalamostriospinal system asserts some of its primitive functions.
One of these is the posture seen in some of the cases we are now
considering. The afferent and efferent paths are those used by the
sympathetic fibres ; and the manifestations are merely an extension to
the sarcoplasmic element of muscle of the phenomena of sympathetico-
tonus, the primitive elements laid bare by partial abolition of cortical
control. It is a posture nearly the same as the senile, but somewhat
modified. Now, what is the inward meaning which it bears? There
are, it seems to me, two explanations of the senile defence mechanism.
Either the old man of primitive ages adopted a bent attitude to show a
possible rival from afar that he was not a competitor in the sexual
contest, or he did so because his blood was running cold. I had hoped
that some help might be gained from the burial posture, for in all times
death has been in human thought associated with sleep. There is an
idiot in one of our wards utterly devoid of sense, unable to stand or
speak, reflexly wet and dirty. When cold this boy lies curled up, all
joints flexed and adducted. You may say, “ He feels cold.” But
consciously he feels nothing, he has much less sense than a fish. The
position is thalamostrial in its entirety. If held up in the four-limb
position of an animal standing he displays postural rigidity, the legs
being stiffened, abducted, extended at the knees, but at the hips flexed
to an angle of 120°. The hands and arms are flexed, in correspondence
with the growth of cortical representation in the arm area. Incidentally,
it was because this boy cried after a full meal that tuberculous
peritonitis was first discovered. Prof. Haddon informs me that climate
is not associated with the burial posture, that predynastic Egyptian
burials were flexed, but that the old Nordic row-graves show an
■extended posture. The sitting burial posture, as described by Rivers
in the earlier Polynesian culture phase, is a much later development
than that to which I now refer, and is connected with religious beliefs.
The other primitive influence on burial posture was over-lordship, a
servile race being buried in an ignominious position, a dominant race
in a dignified, i.e., supine and extended, fearing neither cold nor a night
attack. The flexed posture in sleep protects the vital organs of chest
and abdomen, both from cold and from wounding. I think, therefore,
that the posture of depression is allied to the senile, is probably
produced by the same physiological mechanism in the thalamostrial
system, and that it is defensive. But let it not be thought that these
postures have all the same meaning. They are merely, in each case,

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the remnant of the climbing habits of our arboreal progenitors, and
their allied descent can be traced in the semi-erect gait of the modem
ape.

The Functions of the Cerebral Cortex.

So far I have said little of the higher cerebral functions which are
liable to be disturbed in “ involutionary melancholia.” Little as we
know of cerebral processes, still there are a good many indications as to
comparative probabilities, and it would seem desirable to attempt to
correlate the fragments of knowledge which we possess.

It is a common fallacy that a neurone can at one and the same time
discharge and inhibit. A mountain of false conceptions has arisen
round the laboratory process of electrical stimulation, by means of
which it would appear that a motor neurone can initiate a voluntary
contraction, and that, when not discharging energy, it is at rest.
Electrical stimuli can, of course, overwhelm natural processes and
produce muscular contraction, but by a crude, coarse, foreign factor,
unknown to normal conditions. It appears diametrically opposed to
all we know of nerve energy to suppose that two such opposite
processes as activation and inhibition can go on practically simul¬
taneously in a neurone, or at least can reverse themselves many times
each second, and at the same time to profess to believe that both
processes are the result of chemical action ; all we know of the
building-up of the complex molecules of which the body cells are
composed seems to indicate that vital processes occur by successive
steps, each of which occupies a definite, perhaps even a measurable
unit of time, and that the like occurs when these molecules are broken
down. It is more reasonable to suppose that only one kind of energy
is developed, and that action or inaction results according to whether
there is absent or present that biochemical influence which we call
inhibition. McDougall, in this country, has drawn attention to this as
being the only possible conception, and has worked it theoretically into
the “ neurin ” hypothesis and his “ drainage ” theory of the nature of
inhibition.

As has often been said, all life is a reflex, and tone is a property of
every reflex system. In every cell there exist molecules of extreme
complexity, but a general common principle is at the basis of their
construction. There is a more or less stabile moiety consisting of
conjugated proteins, that is proteins composed of nucleic and
aminoacid-body precursors, and a more or less labile moiety, largely of
a carbohydrate nature, the two being adsorbed to one another. The
ultimate precursor of the carbohydrate unit is for practical purposes
oxygen, and the ultimate end-product is carbonic acid. By the Nile-
blue process the formation of oxygen can be actually observed at the

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synapses, and afterwards its absorption in the nascent condition by the
cells. The changes in cell constitution are brought about by two
classes of specific enzymes, oxidases and reducases; while a third
class, the deaminases, acts mostly on the protein element. These
enzymes have specific precursor zymogens. There are thus continually
going on in the normal cell the comparatively slow, side-by-side, step by¬
step processes of anabolism and katabolism, and these are regulated by
the ordinary laws of enzyme action in regard to reaction velocity,
optimum temperature, reversibility, etc. The general result of this is
that the cell would be continually producing and discharging heat and
energy were it not for the interference of two other processes—reinforce¬
ment and inhibition. Reinforcement is regulated by the laws of
enzyme action, and results both in increased activity of the individual
cell and in the co-ordinated activity of groups of cells; inhibition
depends on the action of antenzymes. In neurones, as in other body
cells, energy and discharge tend constantly to go on, and on the motor
side action would constantly result were it not for the presence of
inhibition.

It is clear, however, that there must be some ultimate activator.
This is found in the constant stream of afferent impulses which are
flowing in, as the result of stimuli from the outside universe impinging
upon the end-organs of the sensory projection systems. These stimuli
are conscious and unconscious, and the unconscious outnumber the
conscious as a million to one. Their ultimate energy is derived from
the electrons reaching the earth from the sun, and if they ceased to
affect our sensory projection systems life would be impossible. Sleeping
or waking, from conception to dissolution, the sensory cells receive a
stream of afferent impulses which continually pass in a forward direction
to the motor side. But these impulses are liable to sudden alterations
in intensity, and their balance is ever varying; consequently one set
or another are ever taking some path of least resistance and breaking
down the fence of inhibition which is erected at the synapses. When
a path is opened to the motor side activity results. All motor
phenomena are reflexes—the withdrawal of the foot from a prick,
hypertonicity in the spastic cord, the psychomotor unconscious postures
of mental disorders, normal “voluntary’’acts and the highest intellectual
processes of creative thought—all are but reflexes, even though some of
the afferent stimuli may have lain chemically dormant in the uncon¬
scious memory for centuries. Deliberation is merely psychic inhibition,
determinism is a law of nerve energy ; no thought or movement occurs
other than what was absolutely inevitable under a given set of circum¬
stances. Free-will is a psychological figment, while the world-old tag,
“ Every woman has her price,” is but the somewhat cynical application
of an universal truth.

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The activity of body cells is regulated by two mechanisms. One,
the older and slower, is hormone action, whereby enzymes from
endocrinic and other glands circulate in the blood-stream; the other,
newer and quicker, is nervous action. The older is still largely used
in the primitive processes of development and digestion, the crowning
edifice of the latter is the cerebral cortex. All processes of normal cell
change depend upon a fine adjustment of both agencies, which mutually
regulate one another in every varying phase. I will not say much
about the decerebrate and spinal dogs in Goltz’s and Sherrington’s
experiments, both of which showed evidences of emotion, but about
the latter there are two points not hitherto mentioned—first, that the
hormone influence was left untouched, and second, that if the lower
cervical cord was transected the phrenics were presumably intact, and
the phrenics have numerous sympathetic connections, and are far more
than merely motor to the diaphragm.

The whole nervous system is, as Hughlings Jackson first demonstrated
so many years ago, divided into a series of physiological levels, each of
which is normally inhibited by the one directly above it. We are
becoming accustomed now to skip a level, for the pyramidal tract acts
directly on the lower neurones, and, as we shall see later, the psycho-
sensory acts on the psychomotor. This inhibition acts through the
afferent side of a lower level, so that the pyramidal fibres are dis¬
tributed, not round the motor, but round the sensory cord cells, and
the anterior corticothalamic tract acts on the ventrolateral nucleus of
the thalamus, not on the striate body. There are the spinal level, the
rubrobulbar, the thalamostriate, and at least three or four in the cortex.
But there is only one main afferent pathway, and this is connected with
the efferent paths at each level, so that if higher inhibition is removed
each level will act in its own appropriate manner. At every level there
is splanchnic as well as somatic representation. As we ascend the
phylogenic scale functions which are of special use in the develop¬
mental environment of the animal tend to move towards higher levels,
and those of less constant use tend to be crowded out, but the
mechanism of each primitive function, although it may rarely be dis¬
played, retains its integrity intact. Thus the phenomena of the
automatic bladder revealed in Head’s carefully nursed cases of spinal
transection by gunshot wounds display the last defences of the human
organism against threatened danger, and the defence phenomena of
the state of depression reveal the functions of the thalamostriate system
deprived of some, but not all, of the cortical inhibitions normally
imposed upon them.

From the most primitive type of vertebrate onwards the thalamen-
cephalon has always been a reflex centre, and from a very early stage the
olfactory lobe has been a part of the prosencephalon. The centres for

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sight were for long attached to the midbrain; concerning the kin-
aesthetic area less is known. The pyriform area, which resembles the
non-mammalian cortex in the sense that it has no supragranular layer,
is, within these limits, highly developed, and is termed by Elliott Smith
the “ archipallium.” So many lower mammals arc macrosmatic that
the large representation of smell is necessary, and in man the archi¬
tecture has, in accordance with developmental precedent, been preserved,
although the functions have regressed. If we examine the cerebral
vesicle in such a transition type as amphioxus we find a dorsal and
a basal mass of “ giant ” cells, from which giant fibres run through
the spinal cord in dorsal and ventral groups to spinal nerves. This is
the prototype of the afferent and efferent cerebrospinal system of the
craniata. Passing to a higher type, a well-developed thalamencephalon
appears in the dogfish, with huge olfactory lobes projecting from
the anterior end and a small cerebral hemisphere between them.
The optic lobes are pouches from the mid-brain, the auditory centres
are in the hind-brain close to the cerebellum. There is a small but
well-developed spinal cord from which giant fibres have disappeared,
only to appear again in higher fishes in connection with the equilibrating
vestibular mechanism to the tail muscles. The cerebral hemisphere in
the dogfish seems to be entirely olfactory, the somatic sensory and
motor mechanism being lower in the mesencephalon. In amphibia
and reptiles the cerebral vesicles are long and narrow, well covering the
thalamencephalon and devoid of a corpus callosum. The anterior
portion isstill olfactory, but the posterior is probably kintesthetic,although
in position temporal. The optic lobes are still separate, placed posteriorly,
but possessing a commissure. In birds the cerebrum is large and rounded,
the corpus callosum is present, the optic chiasma and lobes small; sight
has become cortical. The olfactory lobe is insignificant, but the
cerebellum begins to attain a fair size. The so-called “ voluntary ”
motor tract from the cortex is through the striorubral system and basal
ganglia. In many lower mammals the large limbic lobe is placed
inferiorly, the temporal, probably largely devoted to sight, posteriorly,
and the frontal is narrow and pointed. The pyramidal tract is present,
but Betz cells have not appeared in the cortex.

Betz cells .—These “giant” cells in the human precentral cortex are
homologous to the cells of Meynert in other parts, and give rise to
coarse fibres. They are derived from infragranular elements and are
situated in the lower cortical layers, but send long dendrons practically
to the surface, so that their area of collection is extensive. A more
detailed study of these cells would probably add considerably to our
knowledge of the system followed by neurones generally during their
process of evolution. The general rule is that the further a cell has to
transmit, the larger the body, the fuller the chromophile elements and
the coarser the axon. But, as Mott says, the number of fibrilke in the
axon is the real determinant of coarseness, and this depends upon how

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many muscle or other fibres the cell has to act upon at one impulse.
Hence these large axons always send out many collaterals during their
course. Bolton points out that the infragranular layers are almost alike
in all mammals, and the differences, as we ascend in the intellectual
scale, are supragranular, pyramidal or associational. But as it is not
easy at all times to recognise the granular layer, different interpretations,
many of them wrong, have been put upon the appearance of the cortex.
Kolmer found no Betz cells in the crucial area of bat, hedgehog, rabbit,
mouse, rat, guinea-pig, ox, or pig, but Campbell considers the large
cells present in the pig to be homologous. I am not surprised that
typical cells do not occur in most of these animals, but the rat is a very
intelligent animal, accustomed to apply both hind and forefeet to
discriminating uses other than mere locomotion. Anyone who has
tried to hit a rat with a stick or seen it moving objects with the forepaw
will acknowledge that it displays a quick resource in situations where
phylogeny can give it little assistance, proving that it is endowed with
a psychomotor mechanism of a fairly high order. Dr. Bolton has
kindly investigated this point and informs me that the cortex of the
rat is well developed, but is devoid of the masses of embryonic cells
which confer upon the cat or dog the potentiality of further evolutionary
progress. What I take to be the mode of development of a long
connecting tract like the spinal cord is that it evolves from the purely
segmental arrangement in three stages. First, fibres develop from the
encephalon downwards, growing gradually longer until the whole cord
is connected up, those neurones in one cortical area sending axons
more or less strictly to one somatic area, at first over only two or three
segments. Next, as the need for greater co-ordination is felt, the
“giant ” cells develop, their stout axons containing many fibrillae which
become distributed by collaterals over many segments, although the
parent cells are still retained in one cortical area ; this gives a widely
diffused “ axon reflex,” but not great specialisation of function. Lastly
the stout axons subdivide, as do the parent cells, of course in the
embryonic stage, and each fibril receives a medullary sheath, supplying
only a few lower neurones. But the break-up of the giant cell allows
of ample cross-representation, so that finer movements of parts of a
muscle may be initiated from several cortical areas at once. This
theory is supported by a consideration of the Betz and Meynert cells in
different grades of development and in different cortical centres. The
Betz cells are more abundant in and near the fissure of Rolando, and
fade away anteriorly, disappearing in regions which we know are more
highly specialised, such as the intermedioprecentral, until in the
prefrontal cortex the axons are exceedingly numerous and at the same
time delicate. Long ago Bevan Lewis described various groups of
Betz cells, and Campbell, from cases of old amputations, was able to
show that each of Bevan Lewis’s groups is connected with movements
round a joint. The following groups are recognised: (i) On the
mesial surface of the hemisphere to the foot; (2) at the upper end of
F.R. to the ankle and leg; (3) opposite the lower end of the superior
frontal gyrus to the knee and thigh ; (4) just above the genu of F.R. to
hip and buttock; (5) immediately below genu to shoulder. Opposite
the genu there are none, the need for small and specialised movements

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39 7

never having been felt in the trunk, so that the cells here have never
advanced beyond the first stage. Below the genu there are two
ill-defined groups for the elbow and wrist, where the cells are in process
of sub-division. At the lower end of F.R. the Betz cells have
disappeared and the pyramids in stage three have taken their place, a
development in accordance with the extreme motor specialisation
required for speech and for head and eye movements. The arere for
the former have advanced far forwards in the third frontal gyrus, almost
to the prefrontal area; those for the latter have spread all up the
anterior intermedioprecental region, where they are conveniently
placed for direct connection with fibres from all parts of the limb arete.
We find, therefore, many Betz cells in the leg area, where finer move¬
ments are not required, few in the arm area, where movements are
becoming more and more highly differentiated, none in the neck
and head, where highly organised psychomotor representation has long
been in use. In the prefrontal area there never were any “giant"
cells, highly intellectualised movements having existed there since the
cortex was first formed ; the cells are smaller and the fibres fine. Betz
maintained that there were more large precental cells in the right than
the left hemisphere, showing a more backward stage of development,
also that there were more in adult life than in youth, showing that in
childhood “common sense” in movement is as yet imperfect.
Campbell estimates that there are about 25,000 in each hemisphere in
man, and 13,000 in the ape. If only 150 were used for a small move¬
ment the possible combinations would run to over one hundred places
of integers.

Layers of the cortex .—No one has done so much as Bolton to
demonstrate differentiation of function in the cell layers of the cortex.
Recognising that the small, medium and large supragranular pyramidal
depended for their relative proportions on axonal longitude, he has
endeavoured to simplify previous classifications. The first is the outer
fibre layer, second pyramidal, third granular, fourth inner fibre, fifth
polymorphic. The granular is receptive and transforming, the
pyramidal the association layer upon which par excellence psychic
processes depend, the polymorphic is the primitive layer relegated to
the performance of lower animal functions. It is the pyramidal which
in under-development or regression varies directly with the depth of
amentia or dementia. These fine distinctions are very well as a
general guide, but we know that all layers are concerned in every
process, and in fact some of us would be glad of a few more layers in
our cortex. The pyramidal is the last to develop and the first to
regress; it reaches its highest stage of development in man. That it is
associational is to be admitted, but further, it is a purely intracortical
layer; its axons never go beyond the cortex. The smaller cells connect
with areae lying in propinquity, the larger connect with those lying
further away. This association is intelligence, and inhibition, and
judgment and everything else which we call mind. And the more
complex the association tracts, not only in each centre but between

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centres, and the more the paths are multiplied, the greater the
intelligence.

The granular layer is entirely receptive, and probably receives and
transforms impulses from both within and without the cortex. The
coarse horizontal fibres seen in various paths are the afferent axons
which fibrillate round these small intercalary granular cells. This
layer is especially well-developed in the sensory projection centres,
least developed in the precentral.

The polymorphic layer is the layer most apparent in lower mammals,
and Watson describes its development in various species; as the
intelligence grows, first the granule, then the pyramidal layer, differen¬
tiate from it. In man the destination of the polymorphic axons has
not been traced, but it is a fair assumption that it is the layer which
connects the cortex with older, that is, extracortical parts of the central
nervous system. Bolton shows that this layer remains almost normal
in idiots and advanced dements. In the latter the persistence of
childhood memories in various mental states may thus be accounted
for, but the memories of the idiot are entirely ancestral, and take the
form of reflexes and automatic postures, functions which are almost
purely thalamostrial, but which probably also, as does the posture in
melancholia, require the assistance of the lowest layer of the cortex. I
think there is little doubt that the thalamic radiations, which go to all
parts of the cortex, are in part the axons of these cells, but the difficulty
is to decide whether fibres pass in both directions to every part of the
cortex—that is, whether both motor and sensory areae possess both
efferent and afferent connections. Probably as regards the cortex at
least this is the case.

Pre-Rolandic cortex .—The old discussionsabout psychomotor localisa¬
tion have now died away, and it is recognised that the precentral area
is purely motor. The chief distinguishing features of this area, apart
from the Betz cells, are the prominence of the fibre wealth, the poor
representation of the granular and the great development of the
pyramidal layer. I think this postulates a limitation of function to
acting mainly as a final collecting station for parts devoted to more
highly intellectualised movements, and also that purely afferent stimuli are
collected from a small area only. I believe the coarse horizontal fibres to
the narrow granular layer come from the post-central area, and are the
medium for the immediate transference of certain classes of somatic
afferent stimuli there collected—in fact they are the fibres through which
inhibitory restrictions upon movements terminally act. On the other
hand the axons from the pyramidal layer appear to run in every fibre
layer, zonal, radiary, interradiary and subcortical, and the distribution
must be very wide. Many of the coarse, horizontal fibres seem to run,
from the intermediate postcentral or even further back, right through

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to the intermediate precentral. As we pass forwards to this latter area
the fibres gradually become finer, the cells tend to be smaller as
differentiation of function becomes greater, until in the prefrontal area
the architecture is very fine and the cross-paths intricate. As to the
polymorphs it is probable that the axons compose the fibres of many
tracts to lower physiological levels. Thus the precentral may have a
connection with the sarcoplasmic elements of skeletal muscle. The
anterior corticothalamic tract seems to come from both precentral and
intermedioprecentral nuclei. The intermedioprecentral is the chief
seat of reasoned movements, and several long association tracts have
been described by various observers as having their origin in this
locality and are mentioned by Campbell, the frontopontine tract of
Flechsig, the tapetum, connected by D^jerine and Muralow with the
visuopsychic area, the superior longitudinal band said to connect with
the auditopsychic area, the uncinate band with the rhinencephalon.
It is likely that the presence of the great occipitofrontal fibre bands
connecting chiefly the eye and hand, which run between the visuo¬
psychic and intermedioprecentral areas, have been by many looked
upon as evidence of two great intellectual inhibitory centres in the
parietal and frontal regions. The posterior boundary of the motor
regions is rigidly fixed by the fissure of Rolando, but anteriorly each
area grades into the next as development advances, and no doubt
individual variations are large. When we reach the prefrontal area it
may be that actual muscular results are not represented, but that the
ipemory of high-grade movements, and the intellectual capacity for
doing things in the most economical of various possible ways, and of
profiting quickly by experience, are there chiefly represented. I do-
not see that any evidence hitherto produced in favour of an inhibitory
centre presiding over all cortical manifestations will stand analysis.
The real releasers and inhibitors of movement are the post-Rolandic
projection and association centres, not acting through one centre but as
the result of the balance of all intellectual afferent stimuli. I should
like to quote a case in point. A friend of mine about eighteen years
ago was thrown out of his dogcart and fractured his left frontal bone.
Sepsis led to operation. Before trephining there was double vision
and a difficulty of recalling technical terms. When the dura was
opened pus was found on the arachnoid, the cortex being red and
pulpy. Ten days later no mental defect remained, no loss of memory
or attention, of business capacity, judgment, or any of the higher
intellectual faculties supposed to reside in the prefrontal region. No
subsequent loss ever appeared. Now, a case like this makes one
pause; it is usually explained that the injury in such cases was not
severe enough, that complete recovery of cortical tissue occurred. I
do not believe it; destroyed cortical tissue is not repaired, but the

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associations in this region are so exquisitely complex that functional
substitution is easy. Nevertheless I admit that it would be difficult to
prove that great fronto-occipital inhibiting centres did not exist. The
fibres would be presumably in the third stage of neuronal evolution,
very fine and numerous, the cells of moderate size, closely packed, and
rich in chromophil elements.

Post-Rolandic cortex .—The postcentral is the collecting station for
the afferent fibres conveying certain kinds of bodily sensation. Head
shows that these are only such as demand discrimination, memory of
passive position and movement, the power of exact localisation, com¬
parison of degrees of temperature and touch, and certain afferent
elements of muscular tonus. Crude primary sensations, such as heat,
cold and pain, find no place. The localisation of pain in the cortex,
although this function is registered in the thalamus, might not present
great theoretical difficulty, for pain can inhibit all other sensations, and in
thalamic and peripheral lesions moderate degrees of temperature may be
so interpreted; it could therefore be assumed that pain was registered in
the various memory centres. But there are many difficulties in accepting
this view, for the cortex is anaesthetic, lesions there never cause pain,
and no cases of projection loss involve its presence. When we come
to heat and cold, with their specialised end-spots in the skin, the
difficulties are greatly increased. On the other hand in unconscious¬
ness there is no pain, and although Goltz’s decerebrate dog reacted to
stimuli calculated to be of a painful character more readily than a
normal animal, yet it had no pain memory, whereas lower mammals
and birds, whose cortex is practically infragranular in character, learn
and remember painful experiences readily. We cannot remember
pain, but only the percepts which accompanied it. Therefore what
connection, if any, these crude sensations have with the cortex remains
completely unknown. The granular layer, as in all sensory projection
centres, is strongly represented, and the coarse fibres which constitute
the posterior thalamopostcentral tract end here, although many of them
seem to run on to end in the intermediopostcentral area. It would
appear that there is no rule in the cortex that all communications
between centres must be by way of the primary projection centre; on
the other hand there seem to be a considerable number of paths avail¬
able for every stimulus, and it is this free network between the psychic
association centres which constitutes the higher memory, and, when it
exists to an unusual degree, intellect. The pyramidal layer associates
with the intermediopostcentral and probably other post-Rolandic centres.
The polymorphic layer is rather sparse, and the large, solitary cells,
representing the second stage of development, are found in the leg
area at the vertex. The axons probably go entirely to the precentral
granular cells. The hand is very largely represented certainly in the

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intermediopostcentral, and Head’s cases show that the representation
is not segmental, but that, in injuries in this region especially affecting
the hand, the foot is next to suffer through extension of area, not the
arm or shoulder.

The special points to be noted about the visuosensory area are the
reduplicated granular layer and the poor development of the pyramidal
layer. Bolton showed that this was the end-station of the visual path
from the colliculi, the coarse fibres of which may be seen running
horizontally; also that the outer of the two layers corresponds to the
thick granular layer in the visuopsychic region, about half the cells
being lost in congenital blindness. Mott considers that a portion of
the coarse fibres come from the opposite occipital lobe by way of the
splenium, in connection with the half-representation of the visual fields
implied in stereoscopic vision. The pyramidal layer is poor because
it associates only with the visuopsychic region. In theauditosensory, on
the other hand, the pyramidal layer is well developed, and Campbell
states that the polymorphic layer contains no Meynert cells, few pyra¬
midal and many stellate. The coarse fibres of the auditory path are dis¬
tributed to the well-developed granular layer. Bolton considers that
the want of symmetry between the visuosensory and the audito-
sensory architecture involves a difference between the large number of
the visual and the small number of the auditory images which are
possible, the visual stimuli being largely concrete, the auditory, owing
to the close connection with speech, much more symbolical.

In the visuopsychic and auditopsychic regions the granular, and
especially the pyramidal layers are well represented, and the freest
association occurs between them and the intermediopostcentral,
probably by fibres running both ways. The interactions of these three
centres constitute the aesthetic side of mind, and a summation of
stimuli from them, forming what Head calls a “schema,” is necessary
for breaking down a path to the efferent side, whether this results in
muscular movement or its psychic correlations. A constant succession
of such schemata from the intermediopostcentral cortex is necessary
for even the simplest co-ordinated movement—that is, no regulated
movement can occur unless the immediately prior position of a limb
and the immediately prior state of contraction of every fibre of every
muscle have been exactly registered. These schemata are not purely
visual or sensory, but are integrated outside consciousness, and only
the final result is appreciated. The polymorphic layer in all the sensory
projection areae, and probably in the sensory association areae also,
goes to make up the thalamic radiations, which are distributed to all
parts of the cortex. This theory goes far to explain Watson’s conten¬
tion that this layer is associated with the instinctive memory in lower
animals.

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It is evident that the cerebral cortex represents, in its striation alone,
two distinct physiological levels. The pyramidal layer controls the
psychic aspect of mind, while the polymorphic layer endows with a
certain degree of consciousness the automatic acts of the thalamo-
striorubral level. In different regions the pyramidal layer is seen in
several stages of evolution, until in the prefrontal the cells become
fairly small, of even size, and densely packed, while the fibres are
delicate and intricate. The thalamostriorubral system has reached its
zenith and is now regressing, but in certain aspects of disease displays
its autonomy when stripped of cortical control. In like manner certain
sensory projection arese are regressing, and with the adoption of stereo¬
scopic vision man has definitely plumped for a visuoaesthetic person¬
ality. Smell, so important in some lower animals, is for practical purposes
gone, and with it taste is reduced to a low ebb. So far these speciali¬
sations seem to have followed physical laws of projection. We can
imagine an animal capable of using the waves of ether as a means
of auditory discrimination and memory, but we cannot imagine a dog
able by smell to recognise a companion in Australia. Whether man
will eventually throw hearing overboard it is hard to say, but before
that happens the afferent aspects of speech must be profoundly altered.
Meanwhile the psychic elements of sensory discrimination interlaced
with those of sight are the determinants of our existence. It seems
probable that with the constant enlargement of the frontal, and
especially the parietal regions of the cerebrum, the centres for taste
and smell are gradually being pushed down among the basal ganglia,
following the fate of pain, heat and cold. The microscope, the
telescope and the radiogram are instances of how our psychomotor
cortex can come to the assistance of our psychosensory, and perhaps
convey more than a hint as to the direction in which future evolution
may proceed.

The Cortex in Disease.

To give a complete bibliography of the names of workers who have
contributed to our knowledge of the cerebral mechanisms would not
only overweigh an address such as this, but would give an altogether false
impression of my own industry. It must suffice to mention Deiters,
Hitzig, Meynert, Vicq d’Azyr, Nissl, Gennari, Golgi, Weigert, Flechsig,
Ramdn y Cajal, and the Vogts abroad. When we turn to a list of our
own workers it is a source of gratification to remember that nearly all
have been members of this Association. First I must place Bevan
Lewis, who, with Clarke in 1878, was one of the first to correlate
comparative histological structure with function. From his beautiful
drawings of the cortex and his accurate description of the nests of Betz
cells subsequent workers have taken their start, nor have his claims to

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priority been at all times fully acknowledged. His descriptions of
mental states, written over thirty years ago, are masterpieces of
delightful English, although his arguments were necessarily more
psychological than is now permissible. Then follow Turner, Campbell,
Bolton, Watson, Orr and Rows, Mott, Head. It is impossible to
mention their individual publications, but their conclusions are our
milestones to-day.

The cranium is a closed box and the quantity of fluid contained
therein is practically constant, although the proportions of arterial
blood, venous blood and cerebro-spinal fluid are constantly varying. In
health the last-named is minimal in quantity. Hill and Bolton record
numerous observations on the laboratory animal and cadaver respec¬
tively, which help us to understand the position. As the cerebro-spinal
fluid is secreted by the choroid plexuses of the ventricles it gradually
ebbs away through the foramen magnum into the spinal subarachnoid
space. Sudden cerebral compression b.y injection of fluid will stop this
by driving the brain-stem downwards, and so plugging the foramen.
The brain rests on the floor of the cranial fossae like a lump of putty,
and what cerebro-spinal fluid cannot escape into the spinal subarachnoid
space spreads out over the convexity of the hemispheres, and in the
end escapes into the superior sagittal sinus, through the tufts of pial
tissue called Pacchionian bodies, which lie in lateral lacunae in the
bone on either side of the sinus. These tufts are absent in the lower
animals and in children, and it would appear that their increase in size
as age advances is the ordinary pial proliferation and bone absorption
in response to the toxaemic chemical condition of the fluid. The veins
open direct into the sinus without valves, the anterior nearly trans¬
versely, the posterior in a forward direction against the blood-stream.
The manner in which the venous blood and cerebro-spinal fluid move
up against gravity and into the sinus is this : At every cardiac systole
a positive arterial impulse is transmitted to the brain, momentarily
raising the intracranial pressure by the introduction of arterial blood.
Instant compensation occurs and some venous blood enters the sagittal
sinus. At every inspiration a negative pressure is established in the
chest and venous blood flows down the internal jugular vein, partly
emptying the sinuses. The veins are thin-walled and can respond to
increased pressure by collapse, but the sinuses are isolated by strong
bands of dura mater, and so negative pressure can empty them. At
each positive pressure phase—whether of cardiac systole or expiration,
a little cerebro-spinal fluid is lifted higher up the convexity of the
hemisphere. At each negative pressure phase very little of this runs
back, for the subarachnoid space is not an open river course, but a
sponge or wad of cotton-wool, the trabeculae everywhere sustaining a
high surface tension—in other words it is a series of capillary tubes. It
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could drain back slowly, but the next positive phase gives it no chance
of doing so.

Our chief knowledge of the course followed by the cerebro-spinal
fluid has been gained by observing the process of brain atrophy, and
the distribution of the are* of wasting in dementia, a subject which
Bolton has made his own. Laboratory experiments, involving the
injection of coloured fluids, and observations on the live human
subject through trephine holes, are bound to be more or less futile, for
they entirely alter the hydrostatics of the cranium. I have always
maintained that the atrophy of the pyramidal layer in certain regions
was a result of direct exposure to the action of a cerebro-spinal fluid
charged with neurolytic agents, but it is possible to imagine that this
toxic agent might be brought by the blood-vessels, and that serum
might transfuse into the perivascular and perineural lymphatic spaces
direct from the capillaries. The cortex is supplied by twigs from the
external branches of all three cerebral arteries, and the circulation is
terminal. These twigs end largely on the convexity of the hemisphere,
and it might be that where the fields of supply meet a tendency to
toxaemic thrombosis would occur. For example, over the anterior
portion of the three frontal gyri the anteromedial-frontal and the
intermediomedial-frontal branches of the anterior cerebral march with
the inferior lateral frontal and anterior ascending frontal branches of
the middle cerebral. Again, over the convexity of the posterior pole,
but well in front of the parieto-occipital fissure, the parietal and
temporal branches of the middle cerebral divide the field with the
parieto-occipital and calcarine branches of the posterior cerebral. If a
subminimal bacterial infection from the blood-stream were present,
such as has been suggested earlier in this thesis, the thrombosis would
probably occur, not in the capillaries, but in the smaller arterioles;
although an ischaemic thrombosis, from osmosis of the molecule
through hypotonia of the blood, would occur in the capillaries. But it
does not seem possible that either form of miliary thrombosis could
pick out the pyramidal layer; it would be much more likely to effect
subcortical atrophy, and also arterial twigs fibrillate out in other parts of
the cortex where atrophy rarely occurs, namely the inferior surfaces of
frontal, temporal and occipital lobes. Undoubtedly a great deal of the
loss of weight in atrophic states is due to subcortical injury, for a brain
may lose more in toto than the whole weight of the grey cortex. But
this is secondary, and can be explained in other ways. Thus, in the
middle stages of atrophy, when the cerebro-spinal fluid is running in
comparatively wide lacunae, it raises the arachnoid from the pia, and
the trabeculae and fine vessels are stretched and destroyed. Terminally,
as Bolton points out, gross arterial changes cut off large tracts of cortex,
and destruction accelerates in geometrical progression. That writer

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405

relies largely for the production of amentia and dementia upon the
principle of hereditary “ deficient neuronic durability,” but does not put
forward any theory of the mechanism by which this occurs. My
explanation is that both mental conditions are produced by direct
contact between the pyramidal layer of cells, including the tangential
system of fibres, and a cerebro-spinal fluid charged with neurolytic
agents ; that there may exist a hereditary blood defect which, on the one
hand, prevents development, and on the other causes retrogression;
and that the prime determinant of defective growth and atrophy is the
course taken by the cerebro spinal fluid as it passes over the convexity
toreach the superior sagittal sinus.

If we examine a series of brains from certain classes of aments, from
secondary or senile dements, or from general paralytics in various stages
of leptomeningeal overgrowth, we find that the condition is, subject to
well-defined limitations as to severity and rapidity, roughly similar in
all cases, however widely these may differ in degree. The wonder is,
not that minor differences occur in dural or pia-arachnoidal proliferation,
ease of stripping, quantity of fluid, and distribution of atrophy, but that
in pathological states so diverse, some specific, some non-specific, any
family likeness should exist at all. The chemical processes at work in the
body must differ widely, but the anatomical results on the brain are
similar.

The cerebro-spinal fluid secreted by the choroidal epithelium of the
various ventricles escapes into the subdural space in the fourth
ventricle through the foramen of Majendie near the apex and the
foramina of Axel Key in the lateral recesses. What does not leak down
into the cord is stopped by the sharp edge of the foramen magnum and
proceeds to percolate round to the anterior aspect of the brain stem,
across the inferior and middle cerebellar peduncles and crura cerebri,
until it reaches the cisterna magna. Here for the second time stagnation
occurs and piarachnoidal hyperplasia is seen. The first time was just
as it escaped from the fourth ventricle, where it tended to bank up
between the lobes of cerebellum on either side of the falx, until it
reached a dead end under the tentorium. It does not stay long enough
in contact with the great fibre tracts of the peduncles or pons to do
much harm, although the occurrence of secondary degenerations in
such severely toxic processes as general paralysis must not be entirely
lost sight of in this connection. Meanwhile the putty mass of the brain
is sitting down tight in its bed, and receives a further squeeze with each
cardiac and expiratory impulse. It presses especially upon certain well-
defined spots, the orbital plate of frontal, and in the middle and
posterior fossae. No cerebro-spinal fluid can lodge in these situations
and neither pial proliferation nor atrophy commonly occurs. I rely
upon this fact as evidence that no diffusion occurs through the capil-

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laries, but that all the cerebro-spinal fluid comes from the choroid
plexuses. From the cistema magna the fluid must get out as best it
can, and it diffuses along two well-defined grooves, one, the larger,
anteriorly between the temporal and frontal lobes from the stem of the
Sylvian fissure; the other, smaller, posteriorly along the top of the
anterior edge of the tentorium cerebelli, where the temporal lobe meets
this bony ridge bounding the middle fossa behind, until it reaches the
lateral surface somewhere in the region of the preoccipital notch. The
anterior stream rises up well in front of Rolando and spreads out like a
fan, especially over the posterior part of the frontal gyri until it reaches
the vertex; the posterior stream rises up over the angular gyrus, spreading
over the first and second parietals, until it strikes the vertex behind
Rolando. At first these streams, now coalesced, easily enter the lateral
lacunae, but as the proliferation proceeds entrance is occluded and
the stream turns first forwards, then backwards, seeking other lacunae.
The bulk travels forward and stagnates near the upper part of the
anterior pole, that is immediately over the prefrontal region. The
architecture of this region is anatomically fine, and no doubt also newly
developed regions are chemically more labile, but at any rate especial
neurolysis occurs here. Some of the fluid, as atrophy advances, leaks
down the mesial surface of the hemisphere on each side of the falx
cerebri, but it never goes as far as the corpus callosum, so that we may
conclude that the hemisphere is raised up and tilted slightly outwards
at each positive pressure phase. In general paralysis the frontal lobes,
where free of the falx, are often adherent to one another. It will be
noticed that the regions next most affected are the intermedioprecentral
in front and the auditopsychic and visuopsychic behind. The weak point
of my theory is the comparative immunity of the precentral and post-
central gyri. But even this is relative, for they are much affected at the
upper part. I can only suppose that the great mass of zonal fibres
partly protects the pyramidal neurones, and that possibly these areas,
being comparatively old, possess more chemical stability. Still it is well
to recognise that this is a weak point in the argument. Bolton finds
in the infant at birth and at three months the pyramidal layer to be
slightly below the adult depth in the visuosensory, 35 per cent, below in
the visuopsychic, and 50 percent, below in the prefrontal. The same order
of regression occurs in dementia. He holds that the last to develop is
the first to regress. If so it must be assumed that both phylogenic and
ontogenic priority confer upon the nerve-cell increased chemical
stability. He also finds that next to the prefrontal the posterior ends of
the first and second frontal and the ascending frontal are affected, then
the first temporal, insula and adjacent parietal area, least of all the
extreme posterior pole. Watson finds roughly the same sequence in
juvenile general paralysis. Yet the visuosensory area does not escape.

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for it may suffer equally with the visuopsychic, and as its depth is only
five-ninths of the latter the percentage loss is greater.

We know little of the state of the cerebral circulation in the
psychoses, although the work of Hill and others on the artificial
production of high intracranial pressure proves that the unconsciousness
and convulsions observed under such circumstances are the result of
anoxaemia. The intracranial pressure follows on the general systemic
pressure, and the capillary, venous, and cerebro spinal pressure are
practically the same. There is therefore little tendency for fluid to
pass from capillaries into the subarachnoid space, especially as the
serum, from its greater concentration of ionisable electrolytes, has a
higher osmotic pressure than the cerebro-spinal fluid. The sympathetic
vasomotor system in the cerebral arteries is poorly represented, but its
mechanism is vital. As the blood-pressure in the brain rises or falls,
whether from postural change or other cause, afferent stimuli from
cranial vessels to the bulbar centres cause an instant response in the
well-developed splanchnic vasomotor system, and equilibrium is
restored. When the blood-pressure in the brain rises to a moderate
degree more venous blood and cerebro-spinal fluid are expressed into
the sinuses. When the blood-pressure falls the extra secretion of
cerebro-spinal fluid prevents venous congestion, which does not there¬
fore tend to occur unless there is-obstruction to the return of blood to
the right heart. So venous congestion is the result generally of a low
blood-pressure although not an inevitable result, while a raised blood-
pressure may promote a freer flow through the vessels. In practice the
brain accommodates itself to considerable variations. There is reason
to believe that in states of exaltation and excitement there is a free flow
of arterial blood through the brain, and that in atonic stupor there is
oedema of the tissues. Stuporose patients can be temporarily awakened
to mental activity by a prolonged bath at about no° F., although the
stupor becomes as deep as ever within half an hour of their removal
from it. There is also reason to believe that in states of depression
there is circulatory retardation and venous congestion ; I have observed
this in certain cases in the retina. All the above are due to blood
conditions and do not vary as the general or cerebral blood-pressure,
which may be in any given case high, normal, or low. Immediately the
skull is trephined the hydrostatic conditions are altered, and the
cerebro-spinal flow in some way diverted. I used to recommend
trephining over the seat of cranial wounds where the commotio cerebri
resulted in melancholia, generally with satisfactory results. It then
became evident that the improvement had nothing to do with any
fracture or its site, and was entirely the result of altered intracranial
conditions ; but it is not easy to persuade relatives to allow a serious
operation in the absence of an accident or scar when recovery may

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occur without it. In one case it was clear that actual mechanical
obstruction was the cause of the depression. A man, set. 33, had,
when fifteen years old, fallen off a shed and fractured his occipital bone
against the iron stop of the yard gate. There was extensive old callus
and rugosity around and over the occipital protuberance. After three
years of acute depression with refusal of food and repeated suicidal
attempts, but without noticeable dementia, he was considered to be
dying of inanition. Sir Charles Ballance was good enough to come all
the way from London to dissect the bone off the torcular. All the
sinuses were found displaced and obstructed by bony callus and fibrous
adhesions. Recovery occurred in five months. That was twelve years
ago, and the man has kept well and cheerful ever since, although said
to be “ rather funny,” no doubt from slight dementia. In this
connection we can recall Head’s early work on visceral delusions. One
can occasionally, in difficult heart cases, locate a systolic murmur by
the mental condition, for if the patient is moody and depressed,
especially in the early morning, the diagnosis is mitral regurgitation, if
he is excitable, irritable, irascible or vindictive it is aortic stenosis.
One connects this with the syphilitic origin, the commonest causes of a
cerebral and aortic lesion being combined in one case.

The arteries of the choroid plexuses are central, from the middle and
posterior cerebral, and the veins run direct into the internal cerebral,
which leads through the great cerebral into the straight sinus. These
arteries and veins are comparatively large, the capillary system is short,
and the venous system is particularly susceptible to the negative
expiratory phase. It follows, therefore, that under all conditions of
general and intracranial blood-pressure the choroid pressure will be
slightly higher than that over the hemispheres, the surface frictic/n being
lower. Thus, provided there is the necessary minimum difference in
pressure of 28 mm. Hg., secretion of the cerebro spinal fluid is possible
under all pressure variants within physiological limits, and the develop¬
ment of hydrocephalus, and of distension of the ventricles with pressure
symptoms when the outflow is obstructed, are explained.

It is certain that under favourable conditions micro-organisms can
invade the subarachnoid space, and Marinesco, Lugaro, Van Gehuchlen,
Orr, Turner, Mott and very many others describe the conditions found.
The perineural lymphatic connection with the olfactory fibrils is
especially free. Orr and Rows show experimentally how such
lymphogenous infections occur, but whether any non-traumatic intra¬
cranial infections are haematogenous seems still uncertain. Bruce,
McDowall, Goodall, Ford Robertson and others have investigated the
state of the brain-cells and leucocytes in the acute psychoses, and it is
generally acknowledged that leucocytosis is a protective tissue reaction.
If the count falls off in the later stages recovery is unlikely. Mott has
done more than anyone else to clarify and rationalise our knowledge of
diseased conditions of the cortex, for he almost alone has realised the

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BY W. F. MENZIES, M.L).

409

supreme importance of accurately correlating the mental state with the
laboratory investigation, and of eliminating intercurrent bodily disorders
when weighing the evidence. We cannot say how, for example, the
treponema of syphilis or the trypanosome of sleeping-sickness reaches
the subarachnoid space, but in specific processes associated with glial
proliferation there appears to be capillary osmosis, for how else can we
explain the reaching-out of the neuroglial fibrils towards the vessels,
seeing that fibrillar formation is always chemiotactic ? It might be
supposed that the treponema did not reach the subarachnoid space
until the choroid protection was lost, but the laws of chance forbid us
to believe that it could be found for years in the spinal subarachnoid
space in cases of ataxia, and not in the brain, if the gate of entrance
were the choroid plexuses. Sicard maintains that in tetanic intoxications
of the blood-stream the cerebro-spinal fluid does not acquire tetanising
properties, which suggests that at any rate in the earlier stages of
infection osmosis does not occur. It is also an ascertained fact that
crystalloids, with their low molecular weight, can osmose from the
capillaries into the subarachnoid space. Drugs may be detected within
a few minutes of administration and the crystalloid narcotic and
convulsant poisons must quickly reach the neurones in order to
produce their physiological effects. But the molecule of many toxic
glucosides is larger than that of biliverdin or bilirubin, which are
occasionally, although rarely, found in the brain in general jaundice.
Of course we do not know what protein adsorptions these various
bodies form, but it would appear that the choroidal epithelium has a
wide power of selection, certainly as regards the large molecules of
colloids. Cholesterol, glucose and globulins are found normally in
small quantities free in the cerebro-spinal fluid, and syphilis is one of
the diseases in which these bodies are produced in great abundance
the non-specific psychoses being feebler examples. Whether or not
any of the cerebro-spinal fluid comes from the capillaries direct it is at
least certain that the oxygen does so, and by this diffusion the cells are
nourished. The oxygen content of the fluid is low, but the oxidases
are abundant, those of the grey matter five times more active than of
the white, and Mott has shown that they are especially active in the
granular layer.

There is some clinical evidence that the habitat of the resting form
of the Treponema pallidum is the liver, and from the conditions seen in
hypertrophic cirrhosis, especially in the foetus, in alcoholic cirrhosis,
and from the frequency of gall-stones in enterostasis, it is likely that the
production of immune bodies in the liver is quantitative, not qualitative,
for although the globulin-like bodies are the most efficient activators of
lipolysis the alcoholic liver extracts will also so act to a less extent.
The lipoids increase as age advances; so do bacterial toxine absorption

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and enterostasis. The determinants of dementia in the acute psychoses
are severity plus long duration, but we know that few persons who have
gone through an attack are quite as active-minded as before. Neuro¬
lysis goes on all through the illness, but if this is not too severe or
prolonged recovery is still possible. We do not, however, know why
some cases of depression persist for years and then recover with little
dementia, or if they die of an intercurrent malady little glial prolifera¬
tion is found. Dementia cannot depend directly upon deficient oxygen
supply, for it occurs both in melancholia, where the oxygen-carrying
powers of the blood are lowered, and in mania or general paralysis,
where there is reason to believe oxidation is free. I believe, however,
that states of depression are due to anoxaemia, and the concurrent
pathological processes tend to the loss of the resistant capacity of the
choroid epithelium and so to dementia, the loss being a disturbance of
the balance in the lipoid complexes, especially the lecithins and
cholesterins, and the destruction of the oxidases.

Summary.

It is plain that involutionary processes are independent of the mental
state which may accompany them, although both may in some instances
be dependent upon the same causes; the phenomena are concomitant,
not causative or resultant. Involution is a march of gradually increasing
cytolysis, marked by the fall of the anabolic and the rise of the
katabolic, and depends to quite an appreciable extent upon the power
of reaction of the hepatic antitoxins to the intestinal toxins, the penalty
of failure being defective oxidation. What we call melancholia depends
upon modifications of the same processes, and especially upon excessive
bacterial fermentation and enterostasis. In response to this suboxida¬
tion a sympatheticotonus occurs, the sensori-motor resultant of which is
the depressive emotion. Neither process is necessarily accompanied
by dementia, but this is liable to occur because the destruction-products
of hepatic reaction are present in the general blood-stream. The
physiological foundation of the sympatheticotonus is the ancestral
defence mechanism of the thalamostrial level, the anatomical paths are
those of the involuntary nervous system. The defence mechanism is
not in itself sufficient to produce a psychosis, but requires the influence
of the infragranular layers of the cortex, and these are released from
the association control of the supragranular layers because the oxidases
cannot supply the neurones with sufficient oxygen. Let us suppose a
person receives a severe shock or some such profound afferent stimulus
through the sensory association centres. If he is living well on the
optimum side of liver metabolism his oxidases rapidly deal with the
enterospasm and hyperglycremia thereby produced. We all know
the feeling of morning “crustiness,” which lasts until muscular effort,

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HY W. F. MENZIES, M.I).

41 I

attention to the work of the day and the reflex visceral effect of a clean
bowel have restored the psychic balance. But if the liver is unable to
neutralise the toxic bases from the intestine then acids must be obtained
by lipolysis, for to prevent somatic death the hydrogen-ion content of
the serum must be maintained ; and even now hypotonia and partial
haemolysis may occur, in spite of the reactive efforts of leucocytosis.
The oxidase-reducase system of the body-cells is thrown out of gear
and anoxaemia occurs in the supragranular layers of the cortex, so that
association is diminished and the infragranular layers, the seat of the
unconscious memories and hidden complexes, are released from control,
a state of affairs produced also in some cases of non specific amentia>
where the anoxaemia interferes with the development of areae of later
myelination. The patient is now unable to overcome the sympatheti-
cotonus and begins to live within the vicious circle. If the muscle
glycogen remains unoxidised depression comes on, if the leucocyte
reaction be sufficient and the oxidase-reducase system be unimpaired
excitement may result, if lipolysis be too severe confusion or delirium
occurs. But dementia, whether secondary or of the dementia praecox
type, cannot follow unless the lipolytic products in the blood-stream
gain access to the subarachnoid space, and in the non-specific dementias
this is the case only when the choroidal lipoids are unbalanced. By
reason of the anatomical arrangement the oxidases of the choroid are
resistant, but they are not invincible. The acute psychoses run a
course much like the acute specifics—the acquired immunity is well-
marked, but often not lasting. After dementia has progressed for
some time it becomes stationary, either because immunity overcomes
the toxaemia or because the infragranular layers are more or less
destroyed, and the unconscious memory lost. No one ever saw a
patient die of non-specific dementia, however much the liability to
intercurrent disease may be increased. It is curious that by a system
of inductive reasoning we arrive at the same point from which the
ancient physicians started centuries ago, and ascribe melancholia to the
influence of a deranged liver.

I would not have it thought that any process of mentation can occur
in any one individual layer of the cortex, but there are reasons for
arguing that afferent stimuli are slowly and relentlessly crowded out
from the superficial into the deeper layers, and ultimately, in the course
of development, leave the cortex altogether. The gradual recovery of
the memory after concussion, the slow unclothing of childhood’s experi¬
ences in dementia, and the early liability of the newer neopallic arete
to suffer in disease, all point to the fact that lapse of time leads to
increased chemical stability; and we begin to wonder whether this is
not one of the elements involved in heredity. The cerebro spinal fluid
always contains neurolytic agents in process of removal; only when the

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concentration is in excess does harm follow. If we think of this going
on not for a few weeks but for millions of years, we can imagine, if we
are not too devoted followers of Weismann, that the more stable ids
gradually forsake the somatoplasm and enter into the germplasm, so
that the character of chemical immunity becomes fixed. It is easy to
picture a conjugated protein whose molecule contains, let us say,
700 atoms of carbon and 400 of oxygen, to be a very labile substance,
but which, by acquiring, say, 402 atoms of oxygen becomes com¬
paratively stable although continuing to possess in a large degree much
the same physiological properties. There are many other possible
explanations of inherent neuronic durability, but as they are all entirely
hypothetical we need not further allude to them.

Now by suitable afferent stimuli—that is by the phenomenon which
we call attention—round-about association paths in the cortex of an
individual may be reopened, so that the resultant motor effects which
we call conduct can be brought into harmony with the laws of the
“ mob instinct,” the observance of which is necessary for the preserva¬
tion of the race. This is the art of psychotherapy, and although we
do not know the nature of psychological processes, we can at least make
a guess at the physiological mechanisms upon which they rest, and by
this we are able to define the limits of useful psychotherapeutic treat¬
ment. Thus, such is admittedly useless in the acute psychoses where
attention is seriously diminished, such as states of excitement, confusion
or stupor. In slighter cases, such as depression, with or without hallu¬
cination or delusion, in states of defective will power, or, as I prefer to
put it, in states of disorganised psychosensory association, psycho¬
therapy is of the greatest value in shortening treatment and preventing
chronicity, both on account of the increased cortical oxidation which
mental effort tends to produce and because in psychoanalysis the
closest attention is necessarily paid to bodily symptoms and their treat¬
ment. It is fashionable in some circles to call psychotherapy the “ new
treatment.” It is as old as mankind, and older than any other medical
code. The temporary danger is that it may lead to the neglect of sound
diagnostic methods, and that its application to organic cases, where the
effect can never be more than temporary and may be actually harmful,
may lead in a few years to its falling into disrepute, and the real
advantages of its application to functional cases be lost sight of. It is
justifiable to codify the laws of psychological action as they appear to
our present ignorance, but it is not justifiable to confuse the end with
the means, or to pretend that the ways of psychology are miles apart
from the ways of physiology, and that there is more difference between
them than there is between chalk and cheese. The mob instinct we
know, and the primitive needs of procreation and life preservation we
know, but it is useless for the psychoanalyst to point to repressed

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complexes laid bare by dissolution unless he can show us the ancestral
prototypes of these complexes in the lower phylae. This is the criterion
by which we limit our belief in psychogenesis, for the whole of
physiology teaches that all processes helpful to the animal are pre¬
served, eventually become instincts, and can be traced right through
from mollusc to man, from cord to cortex. Unless the laws of evolution
hold good when applied to psychology, as they do in other sciences, we
have made no real advance, for false analogy is the worst of errors.

I have made an attempt, in the short space at my disposal, to direct
attention to a very few of the points in connection with involutionary
melancholia which seemed to offer a certain amount of ground for
hoping that we are on the way towards a better understanding of the
problems underlying their origin, their mechanism and their results.
The amount of ground to be covered is so vast that it would be
impossible in an address of this nature to work out the arguments in
detail, and so great has been the necessity for concentration that it was
essential merely to quote the principal data at our disposal and then to
formulate the propositions. As a consequence I fear that the steps by
which I arrive at certain conclusions are far from clear. Not only so,
but I confess that I have been able to make very little advance. We
are still hopelessly ignorant of the chemistry of even the simpler body
processes; science waits upon the chemist, but the chemist also waits
upon the clinician. Unless we observe our cases with a more scientific
eye in the future than all but a very small band of workers have done
in the past, we cannot give that help to the pathologist and the chemist
which alone will guide them in working out our problems for us. Are
we to be content for ever to go round the wards daily, chatting
pleasantly to the patients, without any thought as to what their blood-
pressure is, or what type of micro-organism they are harbouring, or why
they are constipated or why noisy? Are we to be content for ever to
sit comfortably over a fire and work out a psychological system covering
their mental processes, their delusions or their dreams ? Can we not
see that psychology is nothing but the hope deferred that maketh the
heart sick, that for want of a genuine, careful, thoughtful, scientific
effort to solve his difficulties mankind has been driven to invent a
system which will satisfy his intellectual needs, until we in this country
are in danger of arriving at the condition of some educationalists, who
have so worked upon parents that their children have been analysed
into a state of conversion hysteria, and upon psychologists so that they
have been forced to roll themselves in a verbal blanket of meaningless
terminology. Why is it that the seeker after scientific knowledge opens
last of all the Journal of Mental Science ? We older superintendents
all know why—it is because more kudos is to be gained from selling a
sow than from sensitising a serum, from taking 2 d. off the maintenance

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rate than from discovering how dysentery is propagated. Yet can we
be blamed ? The man of science has ever been the Cinderella of our
profession, and the beggarly salary of a head clerk is supposed to be
sufficient for the brilliant pathologist. Fortunately at last there appears
a new dawn upon the horizon, and there springs up a hope that central
pressure will replace individual effort. If the ratepayer only realised
that money spent upon scientific investigation would bring a return two
generations later such as the most reckless war profiteer never dreamed
of, in saving of sickness, misery and insanity, every hospital would at
once be provided with its highly-paid scientific staff. The war has
brought over the art of medicine a new spirit, and the brilliant results
attained in preventive fields by organised research have proved that
money so spent is a good national investment. The Board of Control
has commenced a campaign which will have our heartiest support, and
we may anticipate that before many years have passed each mental
hospital will have its triad of trained observers—pathologist, biochemist,
clinician. Scientific team work under each local authority, properly
guided centrally, at last gives promise of discovering certain- of the
determining causes of disease; these discovered, the education of the
younger generation will follow in natural course, to the end that fewer
may require medical treatment and that more will avoid being broken
on the rocks of terminal ill-health. As a small contribution to this end
I have suggested some problems which will, as I hope, raise curiosity
and criticism.

A Study of the Relation between the Reproductive Organs and
Dementia Prsecox. By Dr. T. Matsumoto, Chiba, Japan. With an
introduction by Sir Frederick W. Mott, K.B.E., M.D., F.R.S., etc.
(From the Pathological Laboratory of the London County Council,
Maudsley Hospital, Denmark Hill, London.)

Dr. Matsumoto, who came to study neuro-pathology under my
direction, having acquired a thorough knowledge of the methods
employed in investigating the histology of the central nervous system
and the endocrine glands, expressed a desire to study the microscopic
specimens which 1 had prepared during the last six years of the testes
and vesiculte seminales in one hundred cases of all ages dying in
hospitals and asylums from injury or disease. A full report of this work
was published in the British Medical Journal of November 22nd, 29th,
and December 6th, 1919.

I was pleased to place at his disposal the preparations for the follow¬
ing reasons : (1) Instruction in the histological appearances of the

testes in health and disease; (2) independent confirmation of my own

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observations ; (3) independent inferences as to the significance of the
changes, especially in relation to the sexual functions and dementia
praecox.

As a foreigner he naturally had many difficulties in clearly expressing
his views; I have therefore had to revise many pages and summarise
part of his article in order to limit its length, because owing to the
enormously increased cost of production it is necessary to confine one’s
attention to the description of salient facts and inferences.

As Dr. Matsumoto has returned to Japan I am unable to submit this
MS. and proofs to him, but fortunately I have the advantage of
submitting them to his friend Dr. Morowoka, who is at present engaged
in research under my direction at the Pathological Laboratory of the
Maudsley Hospital. F. W. M.

The Normal Histology of the Testis from Birth to Old Age.

Case i. —New-born infant. Sections of the testis stained with
htematoxylin and eosin exhibited the following microscopical appear¬
ances : The spermatic tubules consist of a delicate basement membrane
enclosing the closely packed embryonic cells. These cells take the
haemotoxylin stain, and under an oil-immersion are seen to consist of a
cytoplasm and nucleus. A nuclear network is very apparent. The
interstitial substance consists of a loose connective tissue, blood-vessels
and lymphatics. In this loose tissue are tubular-like groups of large
polygonal cells, with a large round nucleus often eccentric in position
and staining well with the hiematoxylin. The cytoplasm, however,
stains pink with the eosin and shows a number of minute vacuoles.
These are the spaces occupied by the lipoid granules, which have
dissolved out in the alcohol and xylol used in preparing the sections by
the paraffin method. Frozen sections stained with Scharlach R. and
haematoxylin showed lipoid (red) granules in the cytoplasm of the
interstitial cells.

Case 2 .—An infant four months after birth. The spermatic tubules
are nearly double the size and less completely separated by the
interstitial substance. The interstitial cells of Leydig are hardly visible.
They have passed into the resting stage.

Case 3.—Child of ten years ; died of shock from fracture of pelvis.
The seminiferous tubules have increased in size; they are much more
closely approximated and there is less interstitial tissue. The basement-
membrane is more visible. The tubules are filled for the most part with
embryonic cells, but here and there there is a differentiation into cells
of Sertoli and spermatogonia. Some few of the spermatogonia show
mitotic figures in the nuclei. There is a tendency to a radial arrange¬
ment of the cells, but nowhere is there any evidence of hetero-typical

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mitosis. The cells of Sertoli are recognised by their elongated irregularly
polygonal or spindle shape, and rest by their base upon the membrana
propria of the tubule projecting between the spermatogenic cells
towards the lumen of the tubule. They possess large oval nuclei which
contain relatively little chromatin. The outer part of the cytoplasm
contains a few fine lipoid granules. There are no interstitial cells visible.

Case 4.—Boy, ret. 16; sudden death from injury. The spermatic
tubules are now much larger and closely packed together with but little
interstitial tissue. The spermatogenic cells present a radial appearance
and the nuclei are seen undergoing active mitosis. Spermatogonia and
spermatocytes undergoing hetero-typical mitosis to form spermatids and
spermatozoa are seen in every tubule. Stained with Scharlach R.
and hsematoxylin frozen sections show the cells of Sertoli filled with fine
orange-stained granules. The interstitial tissue contains abundance of
coarse and fine lipoid granules, mostly stained red. Many of these
granules are seen to be contained in the interstitial cells of Leydig,
which have reappeared.

Case 5.—Adult, set. 25; death from shock due to fracture of the
pelvis. As in the last case all stages of spermatogenesis can be seen in
every tubule. The interstitial cells are very evident and contain abun¬
dance of lipoid granules. Lipoid granules are also seen in great
abundance in the cells of the spermatic tubules, especially the Sertoli
cells.

The Histology of the Testis in Different Forms of

Mental Disease.

With this brief description of spermatogenesis as seen in the normal
testis at puberty and adolescence, I will pass on to a brief survey of the
histological appearances seen in specimens prepared from the patients
dying in asylums.

Idiocy and Imbecility.

In several low-grade imbeciles and one idiot there was no evidence of
spermatogenesis. The tubules were shrunken, and their epithelial
contents were for the most part either destroyed as in the case of the
idiot, or remained embryonic in character. There was a marked increase
of the interstitial tissue, as if a chronic inflammatory process had occurred
(possibly syphilitic), and the interstitial cells could not be seen. In
one higher-grade imbecile (who differed also in not being subject to fits)
there was a fairly normal process of spermatogenesis going on.

General Paralysis of the Insane.

A number of preparations from numerous cases of general paralysis,
including a case of congenital syphilitic tabo-paralysis, were examined.

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In all of these active spermatogenesis was seen occurring in some of the
tubes, although in many of the cases there were, by the side of normal
tubules, completely atrophied tubules in which only the basement
membrane and sustentacular framework could be seen.

The interstitial cells of Leydig were especially well seen in those
regions where the tubules were atrophied. This supports the view that
this atrophy of certain of the seminiferous tubules was due to some local
condition interfering with the discharge of the secretion from the tubules
so affected and causing a secondary atrophy. Stained with Scharlach
R. andhaematoxylin, frozen sections show an abundance of lipoid granules
in the Sertoli cells and in the interstitial cells. Many of these patients
died from chronic dysentery, tuberculosis and broncho pneumonia,
nevertheless there was active spermatogenesis observable.

Manic-depressive Insanity.

Preparations from several cases were examined, and active spermato¬
genesis was observed occurring in many of the tubules.

Hospital Cases.

With only one or two exceptions, viz., (1) prolonged and excessive
suppuration and (2) two cases of carcinoma, active spermatogenesis was
visible. Although there was arrest of spermatogenesis in these cases
there was no regressive atrophy.

Dementia Prcecox.

Numerous specimens of testes were examined from twenty cases of
this disease. They may be divided into three groups, roughly speaking,
according to the time between onset of symptoms (as far as could be
ascertained) and death. This examination led to the general conclusion
that the earlier the symptoms came on and the longer their duration
before death, the more pronounced were the histological changes.

In the first stage of regressive atrophy only a few of the tubules
show morbid changes, the most obvious being a diminution in size and
fewer spermatogenic cells, with fewer cells showing active nuclear mitosis,
absence of spermatids and spermatozoa. The Sertoli cells are seen much
more distinctly resting on the thickened basement membrane. The
interstitial tissue in the region of the atrophied tubules generally
speaking is correspondingly increased. The interstitial cells containing
lipoid granules can be seen and numbers of lipoid granules are observ¬
able in the Sertoli cells.

In the second stage many more tubules are similarly affected, but
there may still be some tubules showing all stages of spermatogenesis.
Examined with an oil-immersion lens the heads of the newly formed

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spermatozoa both in the first and second stages show appearances sugges¬
tive of degeneration. They are often of irregular shape and staining
reaction; they present appearances like the degenerated forms described
by Sir Frederick Mott as occurring in the fluid from the vesiculse seminales
of cases of dementia pnecox. Often they have an oxychromatin instead
of a basichromatin reaction with the hremotoxylin and eosin dyes. In
fact there appears to be a general deficiency of the basichromatin
reaction of the nuclei of the spermatogonia and spermatocytes in all the
tubules in this second stage.

In the third stage, which constituted the greater number of the twenty
cases examined, there is almost complete or quite complete arrest of
spermatogenesis. In the most advanced cases (and they are especially
those which were admitted to the asylum in very early adolescence) the
tubules show a very thickened basement membrane and no spermato-
genic cells ; a few Sertoli cells are seen within the tubule and an empty
sustentacular network. Stained with Scharlach R. numbers of large,
coarse droplets of fatty matter of various sizes are seen in the spaces.
The interstitial cells of Leydig can be seen in the first two stages
containing fatty droplets, but they appear to be less numerous and less
distinct in their outline than those seen amidst the atrophied tubules in
the testes of general paralytics. In the third stage the cells of Leydig
are still more difficult to find and the interstitial lipoid is less observable.
The interstitial connective tissue in some of the cases has undergone
proliferation, and it is not uncommon to find therefore a fairly large
testis in which there is a complete regressive atrophy of the spermato-
genic cells. In other cases there is no interstitial connective-tissue
proliferation. In all the cases, however, there is thickening of the
basement-membrane, and instead of one layer of flattened nucleated cells
there are several.

Senile Dementia.

Several cases of dementia senilis were examined. One octogenarian
showed active spermatogenesis in a number of the tubules—indeed, this
case exhibited a more normal appearance than any of the cases of
dementia prtecox. In another of 86, however, there are appearances
resembling dementia pnecox in the third stage, but the atrophy is not
equal to the most advanced cases of dementia pnecox, for here and there
tubules may be seen in which there is evidence of hetero-typical mitosis,
formation of spermatids and an occasional spermatozoon. Most of the
tubes, however, show only the sustentacular framework, a few cells of
Sertoli, and thickened basement-membrane.

Causes of Regression—Atrophy difeussed.

Since chronic diseases do not appear as a general rule to arrest
spermatogenesis in other forms of insanity, including dementia paralytica,

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it may be concluded that the regressive atrophy is primary in origin and
not due to the diseases which cases of dementia prascox so frequently
succumb to, viz., tuberculosis and dysentery. Moreover, several of the
cases examined in which there was marked regressive atrophy of the testes
died after a few days’ illness of acute pneumonia. Organic dementia
does not produce this regressive atrophy of the testis, nor does extensive
brain destruction, whether due to injury, general paralysis, thrombosis or
haemorrhage. It cannot therefore be secondary to the brain lesion.

It is more difficult to examine histologically the ovaries, but Dr. Laura
Forster’s observations show that there is early fibrotic involution of the
ovaries and degenerated follicles in this disease, although similar states
were found in other cases than those which were diagnosed as dementia
praecox. One case carefully examined and reported upon by Staff-
Commander Kojima showed fibrotic atrophy, and this patient died after
a few days’ illness from acute pneumonia.

In an addendum to Dr. Laura Forster’s article, Sir Frederick Mott
describes his examination of the ovaries in some cases of dementia
praecox and other diseased conditions in which early involution occurs,
and thus sums up the situation : Assuming that the degeneration of the
follicles may arise from two causes—(1) nutritional, depending upon the
quantity and quality of the blood-supply to the organ, (2) germinal,
the specific vitality of the follicle and especially the ovum—it is desirable
in any future investigation to study particular methods by which the
finer histological changes in the primordial follicles can be recognised,
so as to determine whether in certain forms of insanity occurring in
adolescence, eg., dementia prascox, a primary degeneration of the ovum
occurs, recognisable in the immature follicles.( l )

Relation to the Endocrine Organs and their Internal

Secretions.

My countryman, Staff-Commander M. Kojima, I.J.N., investigated
the weights of the ductless glands in no cases dying in Claybury
Asylum, and reported that no definite conclusion can be arrived at
regarding the weight of the reproductive organs in the male and
female in relation to body-weight or mental disease, but in certain
female cases in which the thyroid gland was small the ovaries also
were remarkably small. In an investigation which he made of the
histology of the thyroid gland and other ductless glands Kojima makes
the following statement: “ In the first three out of four cases of hypo¬
thyroidism the patient during life had suffered from ovarian disease.
It may be remarked that these were the cases in which there was not
merely a glandular atrophy, but there was also a marked chronic
inflammatory interstitial change; and in these three cases Dr. Mott

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has found a perinuclear chromatolysis of the ganglion cells of the
central nervous system similar to those described by him in conjunction
with Dr. Bran.”

Severe Graves’s disease and myxoedema are rarely seen in the male,
whereas they are common in the female. Dr. Kojima has reported
hyperthyroidism in a case of dementia praecox affecting a male and
hypothyroidism in a female affected with this disease; but there is no
constancy in this result. It seems that thyroid hypofunction in the
female is especially apt to occur at the climacteric period.

In the addendum to Dr. Forster’s article, “The Ovaries in Mental
Disease,” Sir Frederick Mott describes thus the ovaries of a cretin : A
cretin, S. B—, set. 28 on admission to Leavesden, died at the age of 29.
No corpora lutea were seen; atretic follicles, a few immature ova and
dense fibrous tissue. In the left ovary in addition the organ is the
seat of a large blood-cyst.

This fact is interesting, seeing that Dr. Noel Paton in 1917 reported
that the removal of the thyroid gland checks the growth of the gonads.
He also adds that the action of the gonadal secretion is to check
pituitary activity, and increase in size of this gland in the eunuch is
possibly a response to unchecked hypophyseal activity. Suprarenal
and gonadal activities are closely interrelated, and suprarenal hypoplasia
is usually accompanied by genital aplasias or anomalies —vide Sir
Frederick Mott’s articles.

The interrelation of the endocrine organs and the organs of reproduc¬
tion in dementia praecox is a subject worthy of intensive study from a
combined histological, micro-chemical and chemical point of view.
For the regressive atrophy of the sexual organs may be the fons et origo
of a disturbance of the normal balance of the internal secretions and
thereby engender auto-intoxication or disturbance of the normal nutri¬
tional equilibrium of the nervous sytem. Against this hypothesis is the
fact that removal, destructive injury or disease of the reproductive
organs in puberty or adolescence is not followed by dementia praecox—a
fact which makes it much more probable that dementia praecox is a
manifestation of a germinal deficiency, and that the neurones, which in
a normal individual are endowed with a permanent durability for
controlling the life of external relation, undergo, like the germ-cells,
a premature decay. The body is the vehicle for the germ-plasm, and
till puberty all the productive energy with which the individual is
inherently endowed is utilised for the growth of the body so that it may
be fitted for the struggle for existence. In the male the interstitial cells
which provide the sexual hormones fundamental for the sexual instinct
are in the resting stage; at puberty they reappear with spermatogenesis,
and with their appearance is the vague desire that in normal individuals
occasions, sooner or later, an instinctive attraction to the opposite sex.

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The results of this inquiry support the contention of Freud that the
sexual instinct is the great source of psychic energy, but the fact that
the interstitial cells soon after birth pass into the resting stage and do
not appear again till puberty is contrary to the doctrine of the sexual
instincts operating in infancy.

The failure of the sexual instinct, the source of psychic energy and
the elan vitale of youth, may be correlated with the regressive atrophy
of the reproductive organs and the bio-chemical changes of the neurones.
These bio-chemical changes are, in a measure, fundamentally the
same in the reproductive organs and the nervous system of both
sexes; they are probably primarily of nuclear origin, and dependent
upon a germinal inborn defect of nuclear durability.

The other hypothesis is that the defect in the germ-cells may lead to
a disorder of the balance of the endocrine functions, resulting in a
disturbance of the normal nutritional equilibrium of the neurones with
hypofunction and decay. There is some evidence in support of this
hypothesis, but further investigations are required before any definite
conclusions for or against can be arrived at.

The bio-chemistry of spermatogenesis is fully dealt with in the
articles in the British Medical Journal by Sir Frederick Mott. In
a more recent communication to the Psychiatric Section of the Royal
Society of Medicine—“Studies in the Pathology of Dementia Praecox”
—he describes the histological and micro-chemical changes of the
.neurones in this disease.

In conclusion I desire to express my grateful acknowledgments to
Sir Frederick Mott for the opportunities he has offered me while
working under his direction, also for revising, and assisting me in
writing, this article.

Bibliography.

Mott, Sir Frederick, K.B.E., M.D., F.R.S.—“Normal and Morbid
Conditions of the Testes from Birth to Old Age in One Hundred
Asylum and Hospital Cases,” Brit. Med. Journ ., November 22nd,
29th, and December 6th, 1919.

Idem. —“Studies in the Pathology of Dementia Praecox,” Proc.
Roy. Soc. Med. (Section of Psychiatry), August, 1920.

Idem. —“ Microscopic Examination of the Central Nervous System in
Three Cases of Spontaneous Hypothyroidism in Relation to a Type of
Insanity,” Proc. Roy. Soc. Med., 1915, vol. viii (Section of Psychiatry),
PP- 58-70.

Forster, Dr. Laura,—“ Histological Examination of the Ovaries in
Mental Disease, with an Addendum by F. W. Mott, M.D., F.R.S.,"
Proc. Roy. Soc. Med., 1917, vol. x (Section of Psychiatry), pp. 65-87.

Kojima, Staff-Surgeon M.—“The Ductless Glands in no Cases
of Insanity, with Special Reference to Hypothyroidism, with full
Bibliography ,” Proc. Roy. Soc. Med. (Section of Psychiatry), vol x.

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Idem .—“ Studies on Endocrine Organs of Dementia Praecox.” Proc.
Roy. Soc. Med ., vol. viii (Section of Psychiatry).

Paton, Noel—“Nervous Regulators of Metabolism,” Journ. Nerv.
and Merit. Dis., 1915-1917.

(*) My anticipation has been confirmed, for I have found in a case of acute dementia
praecox histological and bio-chemical evidence of degeneration of all the immature
ova, and as they are destroyed there is progressive replacement by fibroblasts.—
F. W. Mott.

Some Cases of Mental Dborder and Defect seen in the Criminal
Courts. By W. Norwood East, M.D.Lond., M.R.C.S.Eng,
L.R.C.P.Lond., M.P.C., Medical Officer, H.M. Prison, Liverpool.

( With the permission rf the Prison Commissioners.)

The accurate diagnosis of the state of mind of the prisoner under
mental observation forms one of the most important, responsible, and
at times exacting duties of the prison medical officer. Practically and
depa r tmentally the cases fall into two groups, according to whether the
prisoner is convicted and serving a sentence, or unconvicted and
awaiting trial ; of the latter, all cases of murder, attempted murder,
attempted suicide, arson, rape, incest and other sexual offences, libel,
or any other offender in whom there is reason to suppose that mental
disorder or defect may exist, are placed under observation on receptiorf,
and a special examination into their mental condition is conducted.
In addition, a considerable number of accused persons are remanded
from the police courts for medical examination, and evidence as to
their mental condition is given on their reappearance in court. During
a recent twelve months evidence was given in criminal courts in 138
cases, and written reports were sent to outlying districts in 8 cases,
instead of evidence being given personally. Of the 146 cases, evidence
was given in 5 murder trials out of 14 murder cases under observa¬
tion, but it is not proposed to consider them in this paper, which
will refer only to the remaining 141 cases; and although nothing of
particular importance is recorded from this small number, the reader
may perhaps glance with some interest at mental disorder and defect
from the view-point of the medico-legal witness.

Thomas Holmes (1) stated that the prison is probably the worst place
in which to study a criminal; others in later years have confidently
asserted that a prison is not a suitable place in which to observe and
examine offenders. But is this true ? In the larger prisons, on re¬
ception, the prisoner for observation is admitted to hospital; he stays
in bed until ordered up by the doctor, and remains in these surroundings
as long as necessary; by this means a suggestion is conveyed from the

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first that he is a patient, with the result that in a great majority of cases
his confidence is gained. Having with my colleagues been trusted
with rare exceptions for many years by prisoners accused of trivial and
grave crimes, it becomes difficult to believe more insight would be
obtained by observation elsewhere. It must be remembered that child
delinquents, who do not come to prison, are not under consideration
now; but I can see no reason to believe that the confidence of an adult
offender will be more readily given by payment to a psycho-analyst
using an elaborate technique in frequent sittings over prolonged periods,
even should such offender have the necessary financial resources. No
more difficulty in prison is generally met ^with in obtaining the co¬
operation of the cultured offender in the mental analysis than with the
less cultured ; either may be as anxious as the doctor to find the reason
for the offence and to ascertain the nature of the disorder or conflict
from which it has arisen. In both, office interviews are usually welcomed,
and probably under no circumstances is a person so liable to react to
sympathy and interest as when awaiting trial, troubled, and in custody.
In the criminal court itself some information may be derived from the
demeanour of the accused, and the officials, police, probation officers,
missionaries, and others frequently supply histories, which, with those
given by the relations of the prisoner, supplement the daily observation,
office interviews and mental analysis by which the diagnosis of the
mental state of the accused person is formed; and no difficulty is
encountered in making an appointment with the relations to obtain
information concerning the offender if a time is fixed in the evening or
on a Sunday, when their working hours are not interfered with.

The old criminal is likely to offer an impenetrable resistance to
mental or psycho-analyst whatever his surroundings may be, but
probably less to the prison medical officer than others, for in the
former he not infrequently recognises an old acquaintance who has
known him for many years. It is a common experience to find the
habitual offender meet his prison officers again with a certain amount
of fellowship and mutual understanding, and most of us have heard
them talk of the years they “ have served in the prison service with you,
Sir,” thereby making some claim to comradeship.

When the prisoner is definitely insane or mentally defective, it appears
to the writer difficult to appreciate that observation and examination in
the ward and office of the prison hospital are disadvantageous to the
formation of an accurate opinion.

Trotter (2) states that “it seems inevitable that the enormously
complex public services which are necessary in the modern state should
set up a barrier between the private citizen and the official, whereby the
true relation between them is obscured. The official loses his grasp of
the fact that the mechanism of the State is established in the interests of

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the citizen ; the citizen comes to regard the State as a hostile institution
against which he has to defend himself although it was made for his
defence.” That this is so generally will probably be admitted by all,
but unless the prison doctor spares no pains in making an accurate
diagnosis of the mental condition of the prisoner, no matter how many
hours it may require, and is entirely sympathetic and professional in
his manner, he will sooner or later be exposed in the witness-box by
the judge or magistrate, who spends his days in weighing the value of
the evidence of witnesses. By his honest endeavours the hostility of the
accused, when such exists, is usually soon broken down.

In the large prisons there are always a considerable number of
offenders who are never under prolonged observation elsewhere—the
border-line cases and the higher grade mental defectives. It is with
the problem raised in the management of these that the prison medical
officer is constantly dealing, and regarding them that the administrators
of the law so often require medical evidence to explain their bizarre con¬
duct in civil life. With these, as well as with more normal persons, the
doctor lives his days, through these he passes some anxious moments,
and perhaps it is not unreasonable to attach some value to his
experience. He soon concerns himself with patients and the motives
for their actions rather than with criminals and crime, and in motive
seeks the keynote of the mentality of his cases. He finds the man who
commits successive burglaries for loot, which he converts into money,
an entirely different personality to the man who repeatedly commits the
same crime to steal a feminine under garment with which to satisfy a
pathological fetichism. In cases of substitution crime he finds the
individual commits one offence to avoid committing some other—the
aberrational patient commits a murder with the intention of getting
hanged, believing suicide is wrong, or the sexual offender commits
arson knowing the punishment for the latter offence is severe, and a
long sentence will prevent for some time any homosexual act. He
very early in his career recognises the fact that much criminality results
from conflict between primitive instinct and herd tradition, and soon
appreciates the value of “ the controlling power from without ” (2) of
the latter; he may come to consider that the success of the modern
treatment of the young offender by the Borstal system is in no small
measure due to its cultivation. He will not have been many days at his
selected work before he comes into contact with those rationalisations,
which may be elaborate, whereby the criminal meets his position and
settles his conflict. He will have full opportunities of studying the
mental mechanisms of persons similarly charged but in different mental
states : the middle-aged widow who in the past sent libellous post-cards
to a clergyman claiming to be his lawful wife, and who on my evidence
was found unfit to plead, not long after had her counterpart in the ill-

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balanced but not insane girl who sent obscene and anonymous letters
to acquaintances and similarly expressed her sex-complex. Looking
below the surface, he understands that the condemned murderer who
passes the interval between his sentence and execution cheerfully may
not be, and often is not, a callous individual, but one who “ represses
his complex by the exaggerated development of the opposite quality.” (3).

Probably, too, he will have better opportunities in prison than in any
other institution for studying simulated insanity, the exclusion of which
is of vital importance in determining the mental condition of the trial
prisoner.

It is hoped the above remarks are unbiassed and not opposed to
progress, but at times there appears to be a tendency to advocate
methods of observation and examination, some of which would seem
definitely antagonistic to public opinion and liable to abuse in trial-
prisoners, and which would, moreover, delay the celerity with which
justice is administered in this country, without adequate compensatory
diagnostic advantage. As Mercier (4) stated, “if punishment is to
deter from crime it need not be severe, but it must be enough to render
the crime unprofitable. It need be no more than this, but it must be
certain and it must be speedy.” On the other hand, it is only just to
recognise the possibility that selected cases of crime, the result of
psychasthenia and certain other conditions, may at times be cured by
psycho-therapeutic measures.

Of the 141 cases, 34 were insane, 39 mentally defective and certi¬
fiable as such under the Mental Deficiency Act, 17 mentally defective
but not certifiable, 12 showed mental disorder not amounting to
insanity, and 39 were classed as normal. In other words, of the 141
cases 102 showed some mental abnormality, while in many even of those
classed as normal the condition leading to the offence was toxic, or
the circumstances were suggestive of alienation to a bench of
magistrates, stipendiary and lay, such as this city fortunately possesses,
alive to the frequent co-relation between mental affections and
delinquency.

Insanity.

The offences committed by the insane cases were: Stealing 9,
attempted suicide 6, drunk and disorderly 5, loitering 4, wounding 3,
threats to murder 1, unregistered alien 2, sexual offences 2, wilful
damage 1, sleeping out 1. The forms of insanity were—Manic-
depressive : Melancholia, 9 cases—responsible for six attempts at suicide,
and one charge each of stealing, loitering, and drunk and disorderly.
Mania, 2 cases—one of insulting behaviour and one sexual offence.
Periodic, 1 case charged with loitering and 2 with stealing. Delusional
insanity: systematised, 5 cases—one each of threats to murder, wounding.

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sleeping out, unlawful possession, wilful damage; non-systematised,
3 cases—one of wounding, one of false pretences, and one drunk and
disorderly. Dementia pnecox was seen thrice in a charge of wounding,
once loitering, and once failing to register as an alien. Acute con-
fusional insanity was also met thrice, in one case each of stealing,
drunkenness, and insulting behaviour. General paralysis of the insane
was responsible for one case of stealing, and one of an alien failing to
register. Secondary dementia was seen in one case of stealing and one
of loitering. Epilepsy resulted in one case of indecent assault, the
remaining case, one of false pretences, being due to undeveloped
insanity. As the majority of the cases were only under observation for
a short time, it will be evident that frequently nothing more than a
provisional diagnosis as to the form of insanity was possible. Only
a few cases presenting some feature of medico-legal interest will now be
related, the remainder presenting no diagnostic or other difficulty.

Case i. —Male, set. 24, single. Felonious wounding. Belief in witch¬
craft co-existing with delusions of persecution. The accused was a
Gold Coast native, who for three years had been cook to a Church of
England missionary, and nominally became converted. About fifteen
months before arrest he joined the British Navy, and served in the
Mediterranean; his ship was never inaction nor mined. No reliable
history of any previous physical or mental illness in himself or relations
could be obtained. Whilst awaiting demobilisation in a hostel set
apart for coloured men, he got out of his hammock in the early hours
of the morning on an important Church of England festival and attacked
another coloured man asleep in his hammock, who was awakened by
receiving a wound 12 in. long across his chest. When asked what he
was doing the accused made no reply, but proceeded to wound the
injured man further with the razor, incising his wrist and opening his
knee-joint, others in the dormitory became aroused, and after a struggle
the prisoner was overcome, saying he was going to kill four other men
he named. When asked why he had done it he first denied it, and
then said, “ I finish now, I no fit do any more; I have crum for the
men say long time I stink and no comb my hair.” Some seven weeks
before prisoner and the injured man had a trivial altercation in a
railway carriage whilst crossing France over some spilt tea, but had been
on good terms subsequently. The four men he mentioned he was
going to kill had never had any quarrel with him. It was elicited that
in the hostel he avoided his companions and sat by himself, but no
particular notice was taken of this, and no one suggested that he was
objectionable in any way. On admission his face was seen to be
scarred by his tribal marks ; his height was 62 in., and his weight 103 lb.;
he showed no signs of bodily disease nor recent drunkenness, and was
apparently an abstainer. He spoke English with a limited vocabulary,
and stated that when at a port in the Mediterranean he believed the
captain of his ship preferred him to another negro, who, becoming
jealous, decided to put crum or ju-ju on him. This was done by taking
the prisoner’s comb with some of his hair attached and making

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“ medicine” with it, and “ calling” the prisoner’s name ; then another
comb similar' to his own was returned to him poisoned with this
medicine. He believed that using this comb made his skin shake, his
bowels to fail to act, and his body to stink so that people avoided him,
laughed as they passed him, and got up and went away if he sat on
a public seat near them. As a result of this he became depressed, and
was ashamed to go out except at night. He believed he was being
killed by the comb, and had several times complained to the doctor
that “ he stinked,”and the other men avoided him. Later he developed
delusions that he was persecuted by me, refused his food, and had to
be tube-fecfc A witness at his trial, who had lived in various parts
of West Africa, described crum or ju ju as a religion or belief in
witchcraft, that a blood sacrifice is frequently made by the person who
considers he is bewitched or had ju-ju put on him to counteract it,
that usually the victim is another coloured man, that if the person who
is ju-ju-cd has embraced Christianity he is most likely to attempt the
blood-sacrifice on a day he has learnt is of special significance in that
religion. It became clear during the examination that the belief in
ju-ju was not to the accused an insane belief, but when he persisted
that the comb poisoned him, made him stink, and to be avoided by
others, his skin to shake and myself to persecute him, there could be
no doubt that insane delusions had become superadded. I expressed
the opinion at his trial that his belief in ju-ju could not be considered
insane, but that his mind was so overwhelmed with his insane delusions
that he was incapable of appreciating the wrongfulness of his act, and
he was found guilty but insane.

The case was somewhat exceptional. Rarely in this country can it
happen that a crime of violence is to be attributed to a religious custom,
and seldom does a medical witness at a criminal trial nowadays in
England find it necessary to point out to a jury that a belief in witch¬
craft may be a sane belief, but co-existing persecutory delusions be
insane. The examination was somewhat difficult and tedious ; an inter¬
preter helped not at all—indeed, the writer when possible avoids such
service, for it often remains uncertain whether in attempting to discover
delusions or hallucinations leading questions are not being put by the
interpreter and one’s own statement innocently distorted. As the case,
however, slowly unfolded, some suggestion as to whither it was leading
became apparent.

Crimes of violence resulting from mental disorder are most frequently
due to alcoholic melancholic or paranoiac conditions, and some of our
most difficult cases are found amongst those paranoiacs whose delusions
centre round the supposed infidelity of wife or husband. Before an
accurate diagnosis can be made it is always of course advisable, and at
times essential, to interview both parties. Even then the problem may
be as difficult as any dealt with in the Divorce Court, and an erroneous
opinion may result in grave consequences.

Case 27.—Male, tet. 50. Threats to murder, paranoia; remanded

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for examination and evidence as to his mental condition. He stated
that his wife was immoral and admitted her unfaithfulness, that she
said she might have given her marriage lines to another man, and saw
no harm in going with other men and misconducting herself with them
when he was at sea, that men on his ship knew of her behaviour and
discussed it. His general condition was poor, but apart from his
statements and the circumstances of his threat, there was nothing
suggestive of mental disease. His narrative was given with quiet assurance
and much circumstantiality, and it was impossible to say if delusions
existed or not until his two sisters and his wife were interviewed, and
convinced me of her morality and his delusions.

Dementia pnecox at times gives rise to legitimate hesitation and
doubt in both convicted and trial prisoners. When one remembers
that indolence and irritability are frequent in both criminals and
patients suffering from this disorder, and may be the only existing early
symptoms of the latter, it will be appreciated that to correctly estimate
the responsibility of a criminal serving a sentence and exhibiting these
symptoms may tax the skill of the observer to the utmost. The disease
may be seen to gradually evolve in such a prisoner, and it is necessary
to place him under observation for a prolonged period to protect him
from the consequences of his infringement of prison rules before he can
be certified as insane. With the trial-prisoner the evidence of the
presence of this disorder may be inadequate to place before the court.
The writer does not hesitate then to state in the witness-box that as a
matter of experience he believes the accused is in an early stage of
insanity, but that the existing symptoms are insufficiently developed to
justify a definite opinion. He believes this to be the only correct
evidence to give; he believes also that such evidence carries more weight
than when an attitude of assurance is adopted on possibly insufficient
grounds.

Case 91. —Male ; age ? Wounding; remanded for evidence as to
his mental condition. He was an Indian, who at the time of the
offence was in an institution when he suddenly attacked another inmate
with a knife, but whether he had any reason for doing this was not
determined. On admission his general health was good, he was usually
mute, and took no notice when spoken to in English. Two Indian
prisoners conversed with him, but he made no sensible reply, nor to an
interpreter, but it became evident he really understood the dialects
they spoke to him as well as some English. He was apathetic, did not
occupy himself at all, had some slight tendency to fixed attitudes,
would smile to himself from time to time for no apparent reason,
and was slovenly. In addition to mutism there was a suggestion of
negativism in some resistance on his part to physical examination. The
writer felt justified in excluding simulation and giving a decided
opinion in this case.

The following was more definite :

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Case 137. —Male, set. 25, single, charged with loitering to commit a
felony. I was present when he first came before the court, and from
his demeanour then considered he was probably insane. He had been
seen by a police officer to approach three intoxicated sailors and place
his hand inside their pockets in full view of the officer. When arrested
and asked what he was doing at the docks at 1 a.m. he said he was
looking for a ship to stow away to get to America. In court he denied
the evidence and repeatedly made contradictory statements. Subsequent
inquiries showed that he held a good record in one of the services, but
not long before discharge had assaulted his superior officer and was
punished. On arrival home his parents considered him strange in
manner and he was medically examined, but his father refused to have
him certified. Soon after this he left home, apparently fearing detention
in an asylum, and arrived from a long distance in this city, and in a few
hours was arrested as related. On admission his general health was
good, height 69 in., weight 160 lb. Slight anaemia was present. He
slept and ate well. He was slovenly and slouchy, apathetic, realised he
was in the prison hospital and wanted to write a letter home, but did
not do so, as there was no writing-paper in the ward, and he never
asked for any. He lied in a simple, purposeless manner, without
apparent intent to deceive; he lacked prudence or foresight. He gave
no connected account of his career, and appeared to have no remorse
for his conduct nor anxiety for his position, and no apparent family
affection. His memory and attention were impaired. He was mildly
depressed, and a tendency to echolalia was noticed. He was temperate.
There was no hesitation in arriving at a conclusion in his case and
giving evidence accordingly : the manner in which the offence was
committed was in itself suggestive of mental disorder when once
alcoholism had been definitely excluded.

The following case belonged to an important group medico-legally :

Case 238. —Male, set. 21, single. Indecent assault. Automatism.
Remanded for evidence as to his mental condition. The offence
consisted in indecently assaulting a little girl, aet. 8, in a public street
close to her home, and in doing so he made some unintelligible remark.
The child went home to her father, who came out and caught the
prisoner, who ran away on seeing him. From information supplied me,
soon after the assault, he “appeared to be in a state of oblivion and
lacking concentration.” Eventually he said he “did not know half of
what he did or did not do lately, and was about done now.” Both
parents alive; father a capable, intelligent man, mother not interviewed ;
no insanity, epilepsy, or intemperance in the family. Accused received
a blow on the head with a cricket-ball at school, but this apparently was
of no importance; eventually he left in the highest class. Shortly after
he had an illness, in which he was delirious, and on recovering joined
the army before he was seventeen years of age, and was on garrison
duty abroad. He saw no fighting, but lost a finger in the army as the
result of an accident. He had been known by the family to be a sleep¬
walker, and had been followed downstairs and watched during this
state by his mother. He had never had any convulsive attack. Lately
he had been noticed at home to be depressed, irritable, and morose,

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and had spoken of being afraid of going mad ; when he did not return
home, owing to his arrest, his relatives thought he had committed
suicide. Since demobilisation he had been for a short time at regular
employment, but the afternoon before the offence, whilst carrying out
his duties, feared he had an attack, to be described later, coming on and
returned home. The next morning he did not feel well enough to go
to his work till after dinner, and it was on his way thither that the
offence occurred. On admission, height 66 in., weight 126 lb. Slight
tremors of eyelids and hands ; pupil reflexes normal, the vision was
defective, and strabismus was present; the knee-jerks were exaggerated.
Memory except during an attack was good ; attention, perception and
orientation good; he was emotional and depressed, and took little
interest in anything, which was corroborated by his father. He denied
masturbation, and was not suspected of this at home, nor did his
manner suggest it; no hypersexuality was detected. He was an
abstainer from alcohol, a moderate smoker, but perhaps an excessive
tea-drinker. He stated he had had frequent lapses of memory, the
fir->t occurring during his convalescence from the illness he had before
he joined the army; he then remembered sitting on the edge of his
bed, and nothing more till he found himself a quarter of a mile away
from home without any idea as to how he came there; his mother
apparently had missed him, and went out in search of him and found
him. This attack was corroborated by the other members of the
family. When abroad he had another attack, and found himself when
recovering being marched round the guard-room by a sergeant who
thought he was drunk. After leaving the army he was out walking,
felt an attack coming on, and leant against a shop. About an hour
after he found himself in a public park a considerable distance away,
the interval being a blank. On other occasions for shorter periods he
had recognised brief attacks with temporary loss of consciousness. He
described that usually before an attack he had a feeling of faintness and
chilliness, that objects became coloured before him until only a red
patch was seen, and then he became unconscious. On recovering he
was generally walking or standing, and always felt “as if he was just
waking up out of a sleep with his clothes on.” He stated he had no
recollection of the offence nor of being arrested, and that there was a
gap in consciousness from walking to his work until a considerable
time after his arrest. He had realised for some time that these attacks
were abnormal, that he was becoming disqualified to earn his living by
them, and that they were getting more severe, and believed he was
becoming insane. In relating this story he impressed one as being
much more concerned with the probable results of his illness than with
the possible consequences of his criminal act. The history of the
automatisms and of his sensations before and after an attack did not
vary at different interviews. Some corroboration was obtained from the
evidence of the police officer on his arrest; his relations knew of the
somnambulism and one automatism at least; his story was given in a
convincing manner ; and after considering all the facts his condition was
regarded as genuine and probably epileptic.

The usual excuse for a crime heard ad nauseam is that the accused

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remembers nothing of the events and that his mind was a blank at the
time. Apart from alcoholism, epilepsy, or definite mental disorder, the
writer holds that occasionally, in certain offences, this may be true.
He believes that he has seen cases—rarely—in which the accomplish¬
ment of a crime has resulted in such an emotional state of terror and
revolt that dissociation followed in a similar manner to that whereby
certain war amnesias were produced. This, how'ever, is obviously
difficult of proof, and difficult to differentiate from Ganger’s syndrome
mentioned by Healey (5), in which the patient’s desire not to know
brings about a state of mind in which he does not know. Even if
conceded, responsibility would be unaffected. In an enormous majority
of the cases in which loss of memory for the events concerning a crime
is alleged, the statement is simply untrue.

Mental Deficiency.

The importance of mental deficiency in criminal work is well shown,
even in the small figures of this series. Out of a total of 141 cases, 56
showed some degree of mental defect, 39 being certifiable at the time
of the examination under the Mental Deficiency Act of 1913, the
remainder belonging to that large class of delinquents—the subnormal.

Of those certifiable under the Act, 14 were accused of stealing, 9 of
vagrancy, 5 of indecent exposure, 2 each of indecent assault, insulting
behaviour, and housebreaking, and 1 each of accosting, false pretences,
abandoning child, threats, and attempted suicide. Of those not certi¬
fiable under the Act, 7 were charged with drunkenness, 4 with stealing,
2 with attempted suicide, and 1 each of vagrancy, wounding, indecent
assault, and indecent exposure. The classification used is of necessity
the practical one of the Act, but the idiot may be said never to cotne
to prison, the imbecile rarely—twice only in the present series, a similar
number to the moral imbeciles. The majority examined were the
feeble-minded, i.e., morons.

The intelligence tests used in the examinations were those of the
Binet scale of 1911. Occasionally some spec al test of another writer
was applied, but the elaborate tests sometimes advocated would seem
to tend to divert attention unduly from the patient’s conduct, which is
the most important concern for those upon whom the disposal of the
case rests. There appears to be a confusing inclination for those
interested in the subject to devise their own tests. The writer only
admits two—a simple ethical perception test, and a wish test—by which
he endeavours to obtain some information concerning the foresight of
the subject.

In the witness-box when necessary the term “ mental age ” is used,
and not that of “ intelligent quotient ” described byTerman.(6) The
value of a medico-legal witness depends not only upon preciseness and

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conciseness, but also upon simplicity, and whilst the former term
explains itself, the latter requires interpretation to lay justices or jury¬
men, and is, in consequence, less preferable, in the opinion of the
writer, for this purpose. In prisoners under observation for a short
time it is not always easy to eliminate the amount of defect resulting
from co-existing ill-health, malnutrition, privations or environment.
Much difficulty may arise in the differential diagnosis between slight
degrees of mental defect and early dementia prsecox, and it is often
impossible to prove that the inebriate is a mental defective within the
meaning of the Act. As a rule one has been unable to trace the
■cause of the defect. Marr (7) states that the percentage of positive
Wassermann reactions varies among the different observers from i's
to 60. Our cases in which this test has been applied are at present
too few to draw any conclusion therefrom.

The idiot and the imbecile must be considered unfit to plead, and
consequently may be dealt with as criminal lunatics ; the feeble-minded
person, however, will usually be technically fit to plead, and the moral
imbecile probably always. Indeed, concerning the latter it is held that
“ moral insanity, i.e., disorder of the moral rather than of the mental
powers, where a man’s intellectual faculties are sound and he knows quite
■well what he is doing, but his moral sense is affected or diseased, is not
yet accepted in England as falling within the rules in Macnaughten’s
case.” (8) In prison work it is found that the imbecile is not a
malingerer, but the feeble-minded and the moral imbecile frequently
are so ; usually the lower the scale of defect the simpler the delinquency,
and the moral imbecile may be an able instructor in crime. When a
defective has a special ability for committing fairly well-planned crimes,
and this is his only ability, it may not be a simple matter to convince
an unsympathetic jury that the accused is highly developed in this one
direction but defective in all others. In Case 84 the only ability
detected in a well-known and observed career was that of escaping
frequently from custody.

The importance of the early diagnosis of mental deficiency cannot
be over-estimated. The vexed question as to the value of the statement,
“ once defective, always defective,” concerns the medico-legal witness
but little; for him the urgent matter is to get the defective delinquent
in such surroundings, not necessarily institutional, where the habit of
crime will not be formed. If this can be done successfully there may
be a chance that the patient eventually will be able to stand alone and
adapt himself to his environment, but if the criminal habit be formed
the probabilities of this event become small indeed. Goddard (9)
states that the feeble-minded person is not naturally wicked or bad, but
when misunderstood and mistreated he does have enough of the
primitive human instincts to react. To this we might add that the

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defective delinquent easily forms a criminal habit, and by the early
diagnosis of mental deficiency numerous patients will yearly be saved
from becoming persistent criminals.

Were it profitable, examples of every gradation, from the imbecile
through the feeble-minded, moral imbecile, subnormal up to the normal,
with the intervening grades, could be given from the series of cases
with which this paper is concerned. It may, however, be of interest
perhaps to quote very briefly a case each of the delinquent imbecile,
feeble-minded, and moral imbecile, and for the rest to state that those
defectives who are not certifiable under the Act form a heterogeneous
group, some probably defective from birth or an early age, but in whom
no sufficient justification for this opinion exists in the absence of any
history. Others belong to that large number of prostitutes and weak-
minded persons who come to prison and fail to quite fulfil all the
definitions of the feeble-minded, together with a large number of
inebriates, many of whom probably, in an early stage of their career,
might have been brought within the definition of the Act, and many
others whose minds have become enfeebled from alcohol or other
cause.

Case 73. —Male, aet. 16. Insulting behaviour; imbecile. Referred
for medical examination. Father died from morbus cordis following rheu¬
matism. No insanity, epilepsy or intemperance admitted in the family.
Patient was the second of five children, and his mother has always
recognised him as being simple. No ante-natal influences to account
for his condition were traced; as a child he was dropped by a relative,
and the family, probably on insufficient grounds, have attributed his
defect to this. He went to a special school, but could never learn to read
or write. Leaving at fourteen he attempted several jobs, but was never
employed for more than a few days before being discharged. He had
had an operation performed on the left mastoid, but the hearing of the
right ear was good; he had had no other illness, but the Wassermann
test was not applied. He was arrested for annoying travellers outside
a railway station. He asked to carry their bags, and when refused
ried to take their bags from them. On admission height 64 in.,
weight 114 lb., head circumference 21 in.; had reached puberty. Facial
asymmetry was present: the right eye was on a lower level than the left,
there was high-arched narrow palate, the teeth were crowded, and the
mandible poorly developed, the ears outstanding; internal strabismus of
the right eye and phimosis were noted, but no organic physical disease.
He gave correct answers to three of the six-year Binet tests, but could
not draw the diamond nor count pennies. He completed three of the
seven-year, one of the eight-year, and one of the nine-year tests, and
graded just within the imbecile limit. He was very easily confused;
his memory, attention, perception, ideation and emotional reaction were
very defective. He had no prudence. When told to cease annoying
the travellers by the police officer he took no notice, and had to be
arrested. He showed no sexual precocity and no special ability; he

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had no friends or companions, no hopes, no wishes, and few desires.
He was discharged at court, after my evidence, to the care of his
mother, and has not been heard of again.

Case 93. —Male, set. 21. Indecent assault; feeble-minded. His
father was not interviewed, but his mother was somewhat defective. No
trace of ante-natal influences ; the Wassermann reaction was negative.
No family history of intemperance, epilepsy or insanity was admitted.
Patient attended school regularly and worked as a bricklayer’s labourer
for some time, but for some months had only worked casually on odd
days. When dark one evening a little girl, set. 4, was playing with
other children in front of her home, when he picked her up and carried
her into an adjacent stable and committed the assault, and was inter¬
rupted by the child’s father, who had been summoned by her playmates.
The accused had never had any serious illness nor accident, had never
had any fits, and never been in custody before, was an abstainer from
alcohol and tobacco, had no companion of either sex, did not read
bad books nor go to pictures, had no hobby, no amusements, and no
special ability. On admission height 66 in., weight 145 lb., somewhat
simian aspect; head circumference 2i|in.; high-arched narrow palate ;
general health good; normal sex development. He answered all the
liinet tests up to eight years, but only one nine-year test and none of
ten years. He was ignorant on matters of ordinary interest and common
knowledge, was apathetic, easily confused, with markedly defective
memory, attention, perception, emotional tone and ideation. He was
indolent and had no initiative, but could carryout simple verbal orders;
he was unable to appreciate the turpitude of his offence, and could not
distinguish the difference in this respect between stealing food from a
shop when hungry if in the possession of money, or without any; he
thought it more wicked to steal a big rabbit thaii a small one, but
could not give any reason for his opinion. When asked what he would
like if one wish he desired could be granted said “ A good feed ” ; he was
already on a generous hospital diet, and his desires did not extend
beyond the immediate present. He had a certain amount of simple
cunning. When before the court he told the magistrate he had been
in hospital all the time in prison, and then at once pretended to have a
fit. His home environment was unsatisfactory, and after my evidence
he was sent to an institution.

In the following case of moral imbecility the patient came, in my
judgment, within the definition of the Act—that is from an early age he
displayed permanent mental defect, coupled with strong vicious or
criminal propensities, on which punishment had little or no deterrent
effect. The legal definition of moral imbecility, fortunately for the
medico-legal witness, does not require a decision of the keenly contested
question as to whether moral defect can exist without intellectual
defect. It, however, unfortunately does not assist in defining where the
dividing line between the moral imbecile and the habitual criminal
should be drawn—a practical point of difficulty in certain cases, and
one which appears to be best met by Tredgold’s view of the mental
defect of the moral imbecile as having no conception of any social or

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moral obligation, and lacking in the higher faculty of control and
wisdom (10).

Case 43.—Male, aet. 21, single. Stealing. Remanded for examination
as to his mental condition. His parents married when twenty-one years
of age; both are alive, healthy, and teetotallers. No ante-natal influence
was traced. He was the youngest of thirteen children. There is no
record of any insanity, epilepsy or intemperance in the family. The
accused has had no serious illness; measles and pertussis left no
sequelae. When about twelve years old he suffered some emotional
stress at the death of a favourite brother. No other possible develop¬
mental influence was found. He did not do well at school, and started
stealing when fourteen years old. At fifteen years he was sent to a
reformatory for theft, but was only detained there a short time on
account of his mental condition. He incited others to acts of insubor¬
dination, was cunning, deceitful, and committed all sorts of petty
thefts from other boys, but seemed to have no idea that he was doing
wrong. He suffered from enuresis, and was recognised there very soon
to be abnormal. Since then he has been convicted for theft six times
and imprisoned once, he has stolen from gas-meters and missionary
boxes, etc., and no criminal charge laid against him ; he is now charged
with stealing, and has five other petty larcenies in different towns
outstanding. He steals small amounts of money or articles of little
value, and usually spends the proceeds on trivialities. His thefts are
committed in an impulsive and stupid manner, showing marked lack
of foresight in the method, slight gain for considerable risk, an absence
of precaution to avoid discovery, a sense of injustice when detected,
earnest appeals for another chance but no real intention to reform, and
no appreciation of the desirability of living honestly. He has no friends
of either sex; his father says he is clever at finding employment but a
fool at keeping it, and he has never been in any situation any length
of time. He twice escaped from institutions for defectives, and on
one occasion joined the army, was shortly found unfit and returned to
the institution he escaped from ; he then escaped again, travelled a
long distance under the seat of a railway carriage and rejoined the army,
shortly to desert, and then came homeagain—a long distance—under the
carriage seat. At the time of his last arrest he was an army deserter,
out the military authorities had no intention to proceed further on
account of his mental condition. He has always been found untruthful
and unreliable by all who knew him. He has marked special ability for
playing music by ear, but has no hobbies and no other amusements.
His height on admission was 70^ in., his weight 120 lb., head circum¬
ference 20^ in.; he showed facial asymmetry, a usual growth of hair on
his body, but scanty facial growth of hair; was of average physical
development; the palate was normal, the teeth defective; general
health fair ; no enuresis now. The Wassermann reaction was negative.
His responses to intelligence tests varied : he answered all the fifteen
years’ tests accurately except the fourth, for which he was credited half.
With the other tests he became obstinate and would not say, but he
was considered not below the average in intellect. He could read and
write well, had a good vocabulary and composed a good letter, but it
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contained obvious untruths which were unlikely to deceive the
recipient. He was fairly well informed on matters of ordinary interest
and common knowledge, but he had no fixity of purpose, was inatten¬
tive, improvident, without wisdom or control, and expected to deceive
people with the most obvious untruths. His home environment had
always been good. His long-suffering parents had looked upon him as
a problem child, and tried to understand him and improve him, and had
been to much trouble on his account, but he lacked family affection
and had no remorse for his conduct, which could not be traced to any
conflict; this, however, even if it existed, was not likely to be revealed
in so persistent a deceiver. There was no doubt that unless con¬
fined in an institution he would always prey upon society, and no
benefit could be anticipated by other treatment. He was sent to a
certified institution on my evidence.

Mental Disorder not amounting to Insanity.

This group of our cases is more important than the small number
comprising it would suggest. Five were cases of war psycho-neuroses,
alone or complicated with alcohol, 1 of post influenzal and 1 of trau¬
matic neurasthenia, 1 of hysteria and alcoholism, 1 of psychasthenic
inebriety, 1 of mental depression and Graves’s disease, 1 of mental
weakness remaining after an attack of insanity, and 1 case of doubtful
epilepsy with psychic symptoms. The offences were 5 of attempted
suicide, 2 of stealing, and 1 each of loitering, wilful damage, false
pretences, burglary, and unlawful possession, but none were of a serious
nature. No case presents features comparable to any other, and it
would be unserviceable to describe each in detail, but a short account
of one selected haphazard may indicate the border-line material dealt
with.

Case 14.—Male, ast. 27, married; false pretences. Of good social
position, his home life had been unsatisfactory and complicated by
conflict; he left it as soon as possible. There were no insane or epileptic
relatives, but some intemperance in at least one near relative. He did
well at school, and never had any serious accident or illness. At the
outbreak of war he was in the merchant service, and as soon as his
ship reached England he enlisted, a volunteer in the army, and later
returned home wounded. Whilst convalescing he had an amnesia
lasting for some days, and was sent to a well-known military mental
hospital, and there was under the care of expert neurologists, who
found partial loss of memory, some of the lost details being easily
brought back by association. He was discharged after some months
improved, but permanently unfit for military service; he soon re¬
enlisted, and in a short time broke down again, had another amnesia,
and was again discharged. He obtained civil employment, but was
unsatisfactory and left. Not long after he married, having only his
pension to live on, and was making efforts to re-enlist when arrested.
After marriage he incurred some monetary loss through sheer lack
of the most elementary prudence, and cashed a small cheque which he

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437

had made payable to himself at a bank at a branch of which he had
formerly had an account, but later in the same day attempted unsuc¬
cessfully to cash a forged cheque payable to himself at the same bank.
The transactions were carried out in such a manner that it was difficult
to conceive how they could escape detection—indeed, he almost seemed
to court it. On admission he presented tremors of the eyelids and
hands, the reflexes were normal, there was slight mental confusion,
marked lack of ordinary prudence and foresight, some apathy and
untruthfulness, and, in spite of the offence, indecision in some of the
ordinary affairs of life. He had not been drinking, and as many
important details are necessarily omitted from this account it may be
unconvincing, but the reality and genuineness of the case were definite.
It was considered that as the result of the war psycho-neurosis some
impairment of mental function remained, which, however, did not
amount to legal insanity, and in view of this opinion the sentence was
correspondingly light, notwithstanding the not unnatural suspicion that
such a defence has come to give rise to, because of the unjustifiable
manner in which alleged shell-shock has so frequently been exploited
as an excuse for crime.

The thirty-nine cases completing our series could not be considered
mentally abnormal, but in no instance was the time spent in the
examination considered wasted. Some were discharged by the magis¬
trate on learning the connection between the offence and their physical
state; we may not be altogether unduly optimistic in hoping that in
others the advice given may have borne fruit. These cases would,
however, fail to hold the attention of the reader should he have per¬
severed with this paper so far. If I have been able to present to him
cases of mental disorder and defect from an uncommon angle, and to
interest him therein, my object has been achieved.

In the early part of this paper reference was made to the assistance
given by the court officials, police, probation officers, missionaries and
-others in supplying histories, when known to them, of the cases referred
for medical examination. The West Lancashire Association for the
Care of the Mentally Defective have placed at my disposal histories of
certain of the cases which have been of the utmost value, and the
writer feels it a privilege to have been enabled to take part occasionally
with those mentioned in their team work for the prevention of
delinquency.

References.

(1) Holmes, Thomas.— The London Police Court.

(2) Trotter, W.— Instincts of the Herd in Peace and War.

(3) Hart, Bernard.— The Psychology of Insanity.

(4) Mercier, Charles.— Crime and Criminals.

(5) Healey, William.— The Individual Delinquent.

(6) Terman, Lewis M.— The Measurement of Intelligence.

(7) Marr, H. C.— Psychoses of the War.

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438 CLINICAL NOTES AND CASES. [Oct.,

(8) Roome, H. D., and R. E. Ross.— Archbold's Criminal Pleading,
Evidence and Practice, 1918.

(9) Goddard, Henry H. —Psychology of the Normal and Sub-normal.

(10) Tredgold, A. F.—“Moral Defectives,” Studies in Mental
Inefficiency, vol. i, No. 1.

Clinical Notes and Cases.

Abstract of a Report on the Mental Division of the Welsh Metro -
politan War Hospital, Whitchurch, Cardiff, September, 1917-
September, 1919. By Major E. Barton White, R.A.M.C.,
Officer-in-Charge, Mental Division.

The Mental Division was opened in September, 1917, with 450 beds
for N.C.Os. and men ; and in September, 1918, a ward for 16 officers
was added.

The total number admitted during the period under review :

From home service only . . officers, 3 . . Other ranks, 193
Foreign service .... ,, 16 . . 1561

Total.19 .. 1754

Table I shows the associated factors discovered as causes in the
total admissions of officers and men. More than one cause has often
been found attributable. The association of general strain of war
service has been omitted, except when this factor has alone been
elicited, since it probably contributed in some degree to the condition
of nearly all our cases.

Notes on Causation.

Heredity. —The large number with an insane inheritance is noticeable,
and only those cases whose parent, grandparent, uncle or aunt, brother
or sister has been certified insane have been included.

Mental stress. —Among other forms of mental stress, infidelity of the
wife left at home appears to have had no small share in producing
worry and insomnia. In nine cases only was any such cause the only
factor established other than general stress of war service, but nineteen
other cases were found where such stress was associated with malaria,
dysentery, or severe wounds.

Prisoners of war. —The life led as a prisoner of war, as described
both officially and by prisoners themselves, in many instances appears
in itself sufficient to have induced mental derangement, and, indeed, in
only one case of the seven admitted was any other factor found, and
that was exhaustion from dysentery.

Head injury. —This consisted of falls and blows, and as the result
of being buried by dlbris after explosion, with or without scalp wounds..

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(Fractures of the skull have been included under “ Brain Lesions,” the
assumption being that some such lesions, however microscopical,
must co-exist.) Such cases were for the most part confused, and some
acquired delusions.

Brain lesions and fracture of the skull were nearly all due to wounds
admitted with or without foreign bodies.

Table I.

Cause.

The only factor elicited
in —

Associated with other
factors than general
war strain.

Total

incidence.

Officers.

N.C.Ob. and
men.

Officers.

N.C.Os. and
men.

Insane heredity .
Neurotic, alcoholic

121

169

epileptic heredity

—

Previous attack .

—

Mental stress

Stress of war service

—

alone.

Privation as prisoner

—

of war

Alcoholic excess

Head injury without

apparent brain lesion

—

Brain lesion

—

Other severe wounds .

—

Heatstroke

—

Explosives .

—

Malaria

Syphilis

—

Dysentery .
Cerebro-spinal menin-

gitis ....

—

Gas poison .

—

Other diseases

”

Heat stroke appears to have been a very definite factor associated
with general stress of warfare. From the cases seen, it seems to have
left a condition of confusion and general apathy, with amentia, loss of
attention-power and concentration. In many of the cases “ heat
exhaustion ” might have been a better term, for only in nine cases was
there a history of any so-called “ stroke.”

High explosives have helped to produce both forms of hysteria, but
few such cases found their way into military mental hospitals unless
some more pronounced psychosis had supervened.

Alcohol plays its part in all wars, whether in an' attempt to drown a
great mental conflict, such as the repression of fear, or as a more liberal
part of the diet in obedience to the advice—“ Eat, drink and be merry,

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CLINICAL NOTES AND CASES.

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for to-morrow we die.” Whatever the restrictions or facilities afforded,
the statistics evidence a low percentage of cases that can be attributed
to alcoholic excess. The incidence is perhaps smaller than might have
been expected. There were no acute hallucinatory forms admitted due
to this cause; the majority were either confused, or had delusions of
reference, etc.

Malaria shows the second highest figure of all factors discovered.
Nor does this figure represent the number of men who had an attack of
malaria at any time during their service, but only the number whose
psychotic symptoms definitely started during the attack. One is not
inclined to put all the blame upon the luemosporidia for the mental
state that has so frequently followed or accompanied the disease.
Quinine has been given in very large doses without question of idio¬
syncrasy, and it is surprising to find the number of people who are
morbidly depressed after even small doses of this drug ; and hallucina¬
tions, probably suggested and induced by deafness and tinnitus, are
on record in civil life. In only two cases of several who had rigors
while in this Hospital was the protozoon demonstrated in the blood.
In thirty-two out of eighty-five cases, malaria was associated with one
or more of the other disturbing factors mentioned in the table.

Syphilis. —The number of cases under “ syphilis ” represents those
cases in which it has been definitely discovered that the disease has
been contracted at some time or other. This will be referred to more
fully under “ General Paralysis.”

Gas poisoning , apart from its physical phenomena, producing great
mental distress, has no doubt contributed towards the production of
states of depression and confusion connected, if not with any definite
poison, with the insomnia and exhaustion so frequently seen.

Previous attacks. —One officer had had a previous attack of mental
disorder, but was not certified insane ; forty-seven men had been certi¬
fied insane, and discharged from civil asylums prior to August 3rd, 1914.

Table II shows the disposal on discharge as permanently unfit for
further service after medical board, and those remaining resident in
hospital on October 1st, 1919, arranged according to mental disorder.

Notes on the Forms of Mental Disorder.

Imbeciles and defectives. —The term “supposed accepted fitness” for
service has been used. When passing through the wards and gardens
of the Mental Division one did not find the majority of the patients the
well-built, symmetrically featured, and intelligent looking youths that
might have been expected. True, there were many of these, but the
large number of obviously congenitally deficient caught the eye first;
stigmata of degeneration were found also in a high proportion of those
whose disability came under the heading of the other psychoses. The

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high percentage of boys and men taken into the Service either imbecilic
or definitely mentally deficient is regrettable.

A few may have given a good account of themselves in the line, but
these must have been exceptions. Though the majority were in labour
battalions, from accounts received from combatant officers many of
them appeared to have caused considerable inconvenience, if not
definite danger, in the front-line trenches, and also at the base, where
they were always a source of anxiety.

Table II.

United Kingdom.

Expeditionary Force.

►

■O

■H

bio

-d

*T3

•p

Ifi

c id

g OJ

■o

C U
2 *

—

a £

Imbecility.

Congenital mental de¬
ficiency ....

149

316

Moral insanity .

—

Melancholia

—

>58

352

Mania ....

—

IO7

Manic-depressive

—

Delusional

268

Confusional

—

180

Stupor ....

—

I I

Delirium ....

—

Dementia, secondary.

—

General paralysis

—

12*

5«

102

Cerebral syphilis

—

Dementia prsecox

—

IO9

Insanity with brain lesion .

—

Insanity with epilepsy

—

Functional disorders.

—

116

Not insane

—

Absentees....

—

— '

—

Totals ....

108

671

4'2

*9*

262

1773

Many could neither read nor write nor even make simple additions.
Several had never been to school, and the appearance of their degenera¬
tive stigmata has been pitiable in uniform. A few were found to be
encumbrances at an early date; others broke down with some super¬
imposed psychosis produced by the change in their mode of living and
army discipline, or ultimately by the effect of exposure to shell fire.

* Found fit to live at home, though not recovered. There were no deaths amongst
the officers, and there were none remaining resident on October 1st, 1919.
The absentees were men who broke their parole while waiting for their Invaliding
Board, and in whose cases there was delay in obtaining the necessary documents
to so dispose of them.

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While many of them may have been expected to be hardly sensible to
such stimuli, the majority that have come under observation appear to
have felt their position acutely. Some deserted in a panic, others
attempted suicide, or indulged in self-inflicted wounds.

The seven cases of moral insanity appear to have been mostly old gaol¬
birds, and it is difficult to be convinced that their mental condition was
in any appreciable way aggravated by their service.

Melancholia affords the second highest number of all the forms of
mental disease admitted, and the highest of those acquired during the
w’ar, i.e. excluding the mental defectives. They formed 19 6 per cent.
of all admissions. The ratio of melancholia to mania is also enormously
increased as compared to the ratio of these states before the war. We
believe that this is in part due to the incidence of malaria, from which
so many of our cases were suffering at the time of the onset of their
psychosis, and also perhaps in part to its treatment. The percentage
of actively suicidal cases was far more frequent than before the war
amongst the depressed, and eight cases were admitted with healed, or
part-healed, self-inflicted throat wounds.

Protracted cases of dysentery—by producing a profound exhaustion
(possibly more than as a result of toxins)—has been counted responsible
for several of these cases, nine of which had been previously certified as
insane and discharged recovered to civil life before the war. Of these
melancholics, over 5V9 per cent, were sent home recovered during the
period under consideration.

These cases differed in no way from those seen prior to the war. Few
of them were acute. Seven of them had been previously certified insane
and about one-half had a psychopathic inheritance.

Manic-depressive insanity. —In twenty-one of the foregoing states of
excitement and depression a definite history of true alternation was
established. The majority were in the excited state on admission.

Delusional insanity .—There have been a large number of delusional
states in the cases admitted. Rather over half of them were able to go
home in from two to six months; the remainder had to be certified.

These cases, whether following alcoholism, or the combination of
several factors, were unusually interesting. They were first thought to be
paranoidal states which were not expected to recover. The delusion of
accusation of being a German spy was frequent. Persecution by superior
officers perhaps was brought about by unaccustomed discipline on a
sensitive mind. The very definite removal of conditions which may
have brought about this state probably had much to do with their
recovery. We had to deal with several dangerous paranoiacs, and much
trouble was made by their agitation amongst other patients, and their
well-planned complaints, both in writing and getting their letters posted to

eadquarters, and verbally to inspecting general officers.

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Confusional insanity. —There were many cases of confusion, and one
would have liked to have had many of them under observation for a far
longer period. Many no doubt were early cases of dementia praecox.
The majority, however, became well enough to be sent to their homes.
These cases had a history of heredity of either psychopathic or neuro¬
pathic origin, combined with exhaustion from wounds or from malaria,
etc. One or two were associated with alcohol in susceptible subjects.
Over io per cent, of the milder confusional states went to their homes.

Stupor. —There were twenty-five cases which have been collected
under this head, but only a few remained to be certified, the majority
making complete recoveries. Five had to be fed artificially for some
time, and three of these recovered. One case who had remained
stuporose for five months was anaesthetised, and a strong current applied
to groups of muscles. All gave strong reactions. The current was then
applied to the larynx. The patient used his voice, but spoke no words.
After the current was removed we asked him a question, to which he
again made some inarticulate noise and lapsed again into a state of
stupor, in which he was transferred some two months later to a civil
mental hospital after discharge from the service.

Delirium. —Only one such case was admitted, and he was suffering
from lobar pneumonia (which unfortunately was not recognised prior
to admission from a local hospital), and died in forty-eight hours.

Dementia (secondary). —These cases were secondary to alcoholic
insanity, or had been previously insane, the dementia supervening
rather sooner than usual with the second attack.

General paralysis of the insane. —Syphilis was definitely established to
have been contracted in 49 cases out of 102 admitted, the positive Wasser-
mann test not being included as a definite positive proof. Twenty-three
showed a history of psychopathic or neuropathic inheritance.

Not more than one or two showed any marked stigmata of degenera¬
tion, and, judging by their pre-war occupations and also their standard at
school, they compared favourably with the other psychoses.

We know in civil life how head injuries appeared to act as a strong
exciting cause in determining the onset of the initial symptoms, and
have had to give evidence concerning such causal factors to help
determine the question of compensation. Such head injuries were found
to have occurred in thirteen of our present cases.

The Wassermann test was made on all of these cases. The following
table gives the reaction :

a. In 46 + in serum, j* in cerebro-spinal fluid.

b. In 22 + „ — „ „

c. In 29 — „ + „ ..

n. In 5 u >> n

All those under “ d ” were repeated after an average interval of three

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to six weeks, and were then -+- in the cerebro spinal fluid in all cases
and in the serum in four of the five.

The frequency of a positive reaction in the cerebro-spinal fluid with a
negative reaction in the blood-serum is noted. It may be that the
anti-syphilitic treatment had rendered the general system free, but has
been unable to take effect on the nervous system when once this has
been invaded.

The Nonne-Apelt reaction was performed in ninety-two cases, and in
all but two was positive. For information regarding Stanford’s nitrogen
contents estimation of the cerebro-spinal fluid reference should be made
to Reports from the Chemical Laboratory : Cardiff City Mental Hospital ,
No. 2, 1919.

Cerebral syphilis. —Nine cases were recognised as suffering from
cerebral lues. The patients showed clouding of consciousness and
confusion with early dementia. Their reflexes were affected to some
extent in every instance, and there was loss of facial expression, with
labial tremor. They did not show the familiar well-marked disturbances
of the paralytic ; excitement and exaltation were absent in every instance.
In all the Wassermann test was positive.

Dementia prcccox. —All three forms of this psychosis were admitted,
the majority being, perhaps, of the paranoidal type, and katatonia the
most uncommon. In about one-third of the cases was a psychopathic
inheritance established.

Insanity with brain lesion. —There were eight of these, including
cases of severe fracture of the skull. Scalp-wounds from severe
blows, with or without naked-eye injury to the bone and periosteum,
have been shown to produce bruising of the dura with varying
degrees of cortico-meningeal htemorrhage. Such patients com¬
plained of giddiness and headache (which is nearly always frontal),
and showed a general mental dulness. Increase in tendon-jerks was
nearly always present (vide Jefferson, Brain , vol. xlii, Pt. II).

Insanity associated with epilepsy. —Several cases admitted diagnosed
as epilepsy had no epileptic manifestation since returning from overseas
and for a period of several months after admission to this hospital, and
this may support the theory of those who believe epilepsy to be almost
entirely functional.

Those cases that had frequent fits since admission were treated with,
intra-muscular injections of collosol palladium, in connection with
which there were none of the depressing sights of degradation produced
by continuous administration of the bromide salts.

Hysteria. —Under this heading are included the so-called shell-shock
cases that found their way into the mental division. Among these
twenty-six there were cases of both conversion hysteria and anxiety
hysteria. There were several constitutional neuropaths.

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Psychasthenia. — Nine cases diagnosed under this heading are also
included in the shell-shock cases.

Neurasthenia .—There were no unusual symptoms, and after an average
residence of two months in hospital the patients were discharged the
Service and sent to their homes.

Mental instability .—These cases showed no definite psychotic sym¬
ptoms on admission. They were given to reacting in an exaggerated
manner to stimuli. They were often the cause of discontent among
the patients in the same ward, and one was not sure what they might do
next. After a period of rest and control they were allowed on parole,
and when their behaviour had been normal from one to two months
they were discharged to their homes, with the exception of three cases
in which psychotic symptoms supervened—or, should we say, came to
the surface.

Notes 071 Treatment.

The results of obtaining cases early for treatment have been evidenced.
This hospital, which, in its civil capacity, is the mental hospital for the
city of Cardiff, is modern and well equipped for the care and treatment
of the mentally afflicted.

Female nursing staff has been employed : a sister, staff nurse and
three or four probationers in each ward of between forty to fifty beds,
with two or three orderlies, have been the usual complement. This has
been conducive to better behaviour and restraint of conduct and
speech among the patients, and the atmosphere of hospital has been
maintained.

Parole for convalescent patients has been very useful in sorting out
cases individually, and gradually testing their self-reliance and stability.

Rest in bed, verandah treatment, and additional diet have been
beneficial in certain cases, especially in those of depression, confusion
and stupor. Continuous warm baths have been used in cases of
prolonged excitement, and where there has been much agitation, with
benefit. Extracts of the ductless glands—pituitary and thyroid—have
been useful in cases of stupor and confusion, combined with massage.

Massage has been most useful in cases where there has been much
loss of muscle tone and sluggish circulation.

Some cases have shown relief by suggestion, though owing to lack of
space there has been difficulty in obtaining privacy and silence for this
purpose. Moreover, the office-work of a mental division leaves but
little time for individual attention.

Exercise and recreation have been well provided for the convalescents
in the form of concerts, bioscope shows, and occasional outings in the
country ; while several men on parole have worked on the farm and
garden during the morning.

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Army discipline has helped in many ways in their management, but
there has been collusion and combined action among the paranoidal
and delusional cases to overcome authority, though without any untoward
incident of note.

There has been no case of suicide or homicide, largely owing to the
conscientious interest displayed in their duties by the staff.

Deaths.

There were thirty-two deaths during the two years under review,
including fourteen due to general paralysis, two to intracranial growths,
and one after shrapnel wound of the brain. Two cases died of
exhaustion after mania.

Remarks.

Though stress of war and its exhaustion have been mentioned, and
this factor alone was elicited in a fair number of cases, there is no
proof that exhaustion, per se, will produce any of the psychoses. If we
could probe each individual case, no doubt we should find some hidden
complex, long pent up, probably since long before the war, had been
released by one or more factors incidental to war service, and thus the
conflict could be recognised. Such a factor, by upsetting conscious
control of repression, such as repression of fear, would bring about a
psychotic state, particularly in constitutional neuropaths, so many of
•whom found their way into the services.

The State, which is largely dependent for its welfare on the fitness of its
manhood, and has to provide directly or indirectly for the maintenance
of the unfit, would do well to consider more seriously the problem of
the mentally unfit—mentally unfit both individually and progenitally.
The war has shown us that with far earlier treatment more can be done
towards recovery.

In conclusion, my thanks are due to Lieut.-Col. E. Goodall, C.B.E.,
Officer-in-Charge of the hospital, for permission to make this report;
to Capt. G. Harper-Smith, R.A.M.C., for valuable help in collecting
cases which had suffered from malaria; to Capt. H. A. Scholberg,
R.A.M.C., Pathologist to this hospital, for the Wassermann tests ; to
Dr. R. V. Stanford, M.Sc., Ph.D., Research Biochemist to the hospital,
for his investigation and report on the nitrogen content of the cerebro¬
spinal fluid; and to Mr. J. O. D. Wade, M.S., F.R.C.S., Consulting
Surgeon to the hospital.

Cases illustrating briefly the Different Forms oj Mental Disorder.

(i) Imbecility. —Pte. A. B—, at. 20. Civil occupation— nil. Father in county
asylum; mother healthy; brother and sister feeble-minded. Stunted growth;
slight asymmetry of bullet-shaped head; features coarse; hair coarse and
untrained; large flat ears with thin helix and Darwin’s tubercle evident; palate

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narrow and lofty. Unable to read or write; says " twice three = nine.” Missing
after short bombardment. Found wandering three days later, refusing to give
account of his actions. Sent home " N.Y.D. Mental.” Mischievous and
irresponsible in hospital ; behaviour improved with discipline. Boarded, dis¬
charged, and sent to his mother.

(2) Congenital mental deficiency .—Pte. C. D—, set. 33, looks 16. Standard II at
school. Helped father wood-cutting. Father, mother and brother insane. Normal
height; no hair on face (on head fine and silky); prominent mammary glands;
arms and thighs rounded. Pelvic girdle wider than shoulder girdle; rudimentary
external genitalia; only one testicle descended; has never experienced sexual
desire; voice high pitched. States he worked as a female domestic servant for
some months. Simple and childish ; depressed and apprehensive after exposure to
shell-fire. Depression and apprehension disappeared in two months. Worked in
ward kitchen ; on parole; discharged to his home.

(3) Moral insanity. —Pte. E. F—, at. 31. Standard III at school; casual labourer,
father inebriate; brother epileptic. Had been in prison for theft. Apparently
troublesome as a recruit: found with other men’s property ; reported by N.C.Os. as
untruthful and unreliable; refused to obey orders. Court-martial; found ‘‘not
responsible,” and sent home as a mental case. Mischievous; could not be trusted.
Outbursts of violent temper ; broke much hospital glass ; impulsive towards staff;
attempted to escape; given to theft; little idea of right or wrong. Boarded,
discharged, and certified for transfer to asylum.

(4) Melancholia. —Cpl. G. H—, set. 29; single; clerk in drapery store.
Parents and grandparents healthy; sister insane after childbirth. Contracted
malaria; treated by large doses of quinine. Became very depressed ; could not
sleep ; solitary and no desire to do anything; attempted suicide by cutting his
throat. Anaemic and wasted on admission ; refused his food ; said he was “ no use,”
and deserved to die because he had failed to do his duty. Sleeping badly ; suffered
from constipation and headaches. Put in bed on open-air verandah; on extra diet
for two months with general massage during second month. Gradually improved;
began to converse more freely and realise his condition. In three months from
admission was up and about the garden; sleeping and eating well; helped nurses in
ward ; put on parole during afternoons. Had no recurrence of fever in hospital.
Discharged after board to pre-war occupation.

(5) Mania. —Pte. I. J—, act. 37; married; labourer. Father insane; mother
inebriate. Previously discharged from asylum, 1910, after mania. Under fire
periodically for three months ; after attack by enemy began to run up and down
trench shouting and laughing. Admitted in excited and exalted state; exagger¬
ated movements of large joints; incoherent speech but answered questions as a
rule. Continually banging on his door, and destructive to his bedding and clothing
and neglectful in habits; singing snatches of popular songs without break during
the night. Continuous hot baths at ioo° F., starting at one hour daily and increased
to several hours. Became quieter, and showed more attention ; took his food
better. In seven weeks walked round garden during morning; lost 17 lb. in
weight since admission ; extra diet (milk, eggs, etc.). Discharged recovered in
five months, when his weight w'as 5 lb. above that on admission.

(6) Manic-depressive insanity. —Pte. K. L—, set. 41 ; single ; labourer. No
history of insane heredity found; previous attacks 1907, 1910. In 1910 there is
evidence that he was in a state of mania; in 1911 he was depressed, but was not
certified. Admitted from overseas ; exalted, excited, noisy, and restless; thin and
pale. Became quiet in a few days, with occasional outbursts of excitement. In six
weeks he seemed fairly well, and his discharge was considered, but he became de¬
jected and solitary, and inclined to refuse his food. These symptoms increased, and
he was discharged after board in seven months and certified.

(7) Delusional insanity. —Pte. M. N—, set. 30; single; clerk. Mother’s sister
insane for two years ; one brother-feeble minded ; two healthy sisters. Had little
sleep for four days during an advance in France. Reported to his N.C.O. that the
men of his company were accusing him of being a German spy. Became very
excited and resistive. Sent to Netley, and transferred next day. Suspicious and
restless; made the same accusations as in France; saw hidden meanings in
ordinary events referring to himself. These entirely disappeared after three months’
rest and extra diet, and he was discharged recovered.

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CLINICAL NOTES AND CASES.

[Oct.,

(8) Confusional insanity. —Pte. O. P—, a;t. 27; single; draper's assistant.
Father drank heavily before marriage. Was very upset by shell-fire, but did not
complain. Began to sleep badly ; found he could not carry out instructions owing
to losing his memory. Remembers nothing more till he was on hospital ship ;
reported by M.O. to be confused and restless, refusing his food, and unable to
account for himself. On admission he appeared to have improved, and said he
thought the men noticed that he was a coward ; he complained of frontal headaches
and constipation. He was put to bed on verandah with extra diet. Gained 5 lb. in
weight in one month; gradually improved and when allowed up, spent his time
in the garden and helping nurses in ward. When discharged as recovered there
were still some three or four days in France he could not account for.

(9) Stupor. —Pte. Q. R—, ait. 32; single; clerk. Reported sick with headaches
and loss of energy ; went back in the line ; a week later was found wandering,
unable to account for himself. When in hospital at the base became silent and
anergic ; lay in bed unable to help himself in any way ; refused all food. Was in a
state of complete stupor when admitted ; lay still in bed staring at ceiling ; insensi¬
tive to pain. Was anaesthetised; used his voice but did not speak. Did not improve,
and after seven months was discharged to civil mental hospital.

(10) General paralysis. —Pte. W. X—, aet. 27; single; coalporter. Father
alcoholic. Contracted syphilis 1911 ; enlisted 1914 ; served in Gallipoli and France.
October, 1918, became very excited, exalted in manner, and emotional. On admission
restless, destructive to clothing, and neglectful in habits. Pupils unequal, L.>R.,
very sluggish to light; knee-jerks exaggerated; much loss of muscle tone.
Romberg's sign ; face expressionless; speech slurred ; paresis of lips and buccinator
right side; tremors of hands and tongue. Wassermann + in serum and cerebro¬
spinal fluid. Nonne-Apelt +, N.N. 28. Cell count = 25 per c.mm. At times he
stated he was “ King of France,” and at others, "Lord of the Earth.” He was
degraded in habits, and tore his bedding. In this state he was discharged to an asylum.

(11) Cerebral syphilis. —Pte. B. A—,set. 33; single; painter. Father in asylum

twice " through drink.” Contracted syphilis 1914. Served in Egypt and Pales¬
tine. Reported dull and lethargic ; and complaining of headache and malaise;
unable to do his duties, October, 1918. Admitted in a state of confusion. Pupils
equal and contracted, reacted little to light; knee-jerks dimininished equally; tremors
of hands and tongue ; memory very defective. Sat about all day unable to occupy
himself; slept heavily at night; became demented fairly rapidly, and neglected
himself in every way. Wassermann test was — — in serum, and " retarded ” only
in cerebro-spinal fluid. One month later cerebro-spinal fluid was — —. He was
discharged in this state to an asylum. ,

(12) Dementia prcecox. - Capt. B. B—, set. 26; single; 6th form, public school.
Eleven years ago when Resident House-Physician at Bethlem Royal Hospital,
London, we knew his father as a G.P.I. He died there. Strong healthy lad with
no stigmata. When overseas became suspicious, and wandered about alone. On
admissioi) he was suffering from visual and auditory hallucinations ; was destructive
to his clothing, and faulty in habits ; would attempt to stand on his head, and strike
various stereotyped attitudes. He was negativistic ; rather exalted, and inclined to
be impulsive ; spoke in a pedantic manner with staccato voice; lapsed frequently
into a state of confusion. There was no loss of perception-power. He was kept in
bed at first, and had extract of pituitary in small doses. He became more reasonable
though peculiar antics continued. He was transferred to a private institution.

(13) Insanity -with brain lesion. —Cpl. B. C—, set. 28; single; clerk. No
neuropathic inheritance; previously healthy. Shrapnel wound left temporo-sphe-
noidal region six months previously ; healed on admission. Complained of dizzi¬
ness and acute headache over whole of left side ; loss of memory, and inability to
collect his thoughts ; was confused, depressed, and unable to give a connected
account of himself. X-ray showed foreign body just above the left lateral sinus.
Operated on by Mr. J. O. D. Wade, M.S., F.R.C.S., Consulting Surgeon to the
hospital. Foreign body removed; wound drained; healed rapidly. Headaches
gradually disappeared ; memory returned almost completely ; no attacks of vertigo.
Patient discharged recovered to his previous occupation.

(14) Hysteria.

Conversion hysteria. —Pte. B. F—, aet. 33 ; married; three children ; photo¬
grapher. Wounded slightly in leg, June, 1918; under shell-fire for long periods.

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449

Reported to have become very excitable, and complaining of great pain over scar •
was tremulous and restless ; seven days later he became mute In this condition
he was admitted. He would write readily. He complained of frontal headaches and
dizziness; he was hypochondriacal generally; he would often limp with the lee
that had been wounded. He was examined by the consulting surgeon who found no
cau„ tor limping. Pupil, large and very sensitive; k„.e.jerks g ve“ eiaggei
o her reflexes normal. Several attempts were made to get him to speak, and finally’
after about six weeks, he was persuaded that he could speak, and after repeating a
few words could string a sentence together. He contracted influenza, and agfin
became mute for five or six days, but there was less difficulty then in persuading
him that he had not lost his voice. He had no further troublewhen he got up aftef
the attack of influenza, and appeared to have forgotten the scar on his leg H
. “CP 1 - B -G-, *t 29 ; single; butcher’s help. Reported to have

had fits in h ranee. Admitted in a state of confusion ; stated that he remembers
waking up from a dream, and being shouted at and shaken by some orderlies and
a nurse; this was after a bombardment. On admission he was very shakj and
timid ; pulse rapid and rather full; hands were cold and blue and trembling *Was
possessed of some unreasoning fear; had to be reassured as to the identitv of
strangers, where he was going, and who would be there, etc. He had headaohpc
and said the "light hurt his eyes.” He dreamed every night of befng forced tokii
someone ; confessed to the chaplain that he had killed one of the enLy and cou d
not get over it ; there was very slight bilateral thyroid enlargement which he
was certain had not existed before the war; his terrifying dreams pe^isted nor
could he reconcile with h.s conscience the fact of his having shot one of the enemy
He slept badly, and had obviously lost weight. He was put to bed on the verandah'
with extra diet; rarely was he given any sedative at night. General massage was
applied, and his colour improved ; the pulse became steadier, and he wa^ soon
sleeping better but it was some ten weeks before he entirely lost his dreams and
could discuss having killed one of the enemy without signs of distress. It ’is of
interest that the thyroid enlargement had almost disappeared in three months

(15) Psychasthenia- Pte. B. H-, ret. 31 , married; clerk Had £n an
athlete. Was in much fighting in 1915; did not get wounded. In 1917 a shell fell
outside the hut he was in, and blew in a portion of the side. He waswriting to hi«
N fe ‘t W3 j destr .°>’ ed b r dibris, but he was not hurt beyond beingfhak^n

2 d 7, he be'ieved the destruction of the letter he was writing svmbolised the
death of h.s wife at home at that time. He became sleepless, and obsessed with
this one idea On admission he was pale, and appeared exhausted; his sleeping
improved, and he became less restless; he told me he thought his wife must bf

? Cad ’ jVI? trU j hC h f d n0t heard fr ° m her Slnce his " shock." His wife was sent
for, and beyond an almost constant fear of losing her he rapidly improved He
gamed oyer a stone in weight during his five months in hospital. He was then sfnt
home with h.s wife, and wrote since to say that he was back in his “ old job ”
feeling very much better.” ‘ 1

December, 1919.—Since the completion of the above report the
Mental Division has been closed.

There were remaining resident on October 1st, 1919, 279 men and
since that date 86 more have been admitted.

lotal discharges and transfers from October ist, 1919, to December
10th, 1919: 365. Total admissions from September, 1917, to Decem¬
ber, 1919: officers, 19; other ranks, 1840.

Disposal :

Total recovered . . Officers 15 . Other ranks 914

;; died ..." 1 ■ »

„ transfers ” 1 . ” \

„ absentees .... _ ”

Total

1,840

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OCCASIONAL NOTE.

[Oct.,

Occasional Note.

The Annual Meeting of the British Medical Association—Section of
Neurology and Psychiatry.

The success of the Section of Neurology and Psychiatry at the
meeting of the British Medical Association at Cambridge in July-
afforded abundant evidence of the increased interest in the problems of
mental and nervous disorder. The excellent arrangement, by means of
which the members of the Section were entertained at Trinity College,
did much to promote the success of the meeting, in so far as a number
of informal gatherings and discussions were rendered possible, and the
opportunity was afforded for the development of social relationships
between workers in different fields of interest. The Section was,
furthermore, especially fortunate in having Dr. Henry Head as its
President. The influence of his personality was a constant source
of inspiration, and his wide and vigorous outlook served to create
an atmosphere of enthusiasm, which was sustained throughout the
discussions.

In his opening address on the early signs and symptoms of nervous
disease Dr. Head approached the subject from the broadest aspect,
and emphasised the necessity for the formulation of basic conceptions
and general principles in relation to nervous disorder. Especially
interesting to psychiatrists were his observations on what constitutes a
“ disease ” of the nervous system. The following sentences from the
address express the feeling of many in respect to mental disorder:
“ Many physicians seem to consider that morbid manifestations can be
divided into definite ‘diseases,’ and discuss their distinctive characters
with the solemnity of a botanist of the old school debating the limits of
species. They assume that when they have given a name to some
morbid condition a diagnosis has been made. This fallacy is apparent
in all official nomenclature of disease. Diagnosis to be complete must
be a three fold process. First, by careful examination we elucidate the
nature and extent of the loss of function which constitutes the morbid
condition. Next, we translate these symptoms and signs into terms of
some local affection ; if there is reason to believe that they are due to
organic destruction, we seek to determine the situation of such gross
changes. Finally, if possible, we must discover the nature of the
underlying pathological process.”

Much more than neurology has the progress of psychiatry undoubtedly
been hampered by the “disease-entity” incubus, and the above
observations were singularly relevant to the discussion on dementia
prsecox and its relation to other disorders, which was opened by

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Dr. Bernard Hart on the following day. In a comprehensive and judicial
survey of his subject Dr. Hart confined himself to its broader aspects,
and emphasised the fact that the nature and causation of the condition
had still to be made known, and that even the question as to whether
or not it was a definite entity had not been adequately solved. He
expressed the view that any adequate formulation of the essential
nature of dementia praecox must combine both physiogenic and
psychogenic aspects, and this could best result from a consideration of
the disorder of dementia from the point of view of biological reaction.
In the interesting discussion which followed, in which Dr. Bedford
Pierce, Sir Frederick Mott and many others took part, the practical
side of the question was emphasised, and the general impression created
was that of considerable dissatisfaction with the clinical implications
which the term “ dementia praecox ” conveys. It was pointed out by
various speakers that the diagnosis of dementia praecox, based upon a
careful survey of the symptoms, was frequently made; and yet these
cases were often found to make a satisfactory recovery. Such expressions
of opinion, based upon actual clinical experience, are of considerable
significance; and they constitute a striking instance of the fallacy, to
which Dr. Head referred, of regarding the attachment of a name to a
group of symptoms as constituting a diagnosis. That a large number of
cases of mental disorder in young people—and older ones—exhibit a
tendency towards progressive mental deterioration, which is characterised
by defects of interest, incongruity between the thought processes and
the affective and emotional reactions, and feelings of being influenced
and controlled, is of course indisputable. To regard, however, the
presence of schizophrenic symptoms as necessarily indicative of a
deteriorating psychosis is more than the facts warrant. Not only
katatonic and acute hallucinatory states but also paranoid conditions,
with hallucinations, passivity states, and ideas of reference, are frequently
of a temporary and benign character. The prognosis cannot be
estimated solely upon symptoms ; the personality or soil on which the
symptoms are engrafted, their relation to situations to which the
individual has had to adapt himself, the suddenness of the onset, and so
on are all factors which have to be considered in each separate case
before estimating the possibility of recovery. The erroneous significance
which may be attributed to mental symptoms finds a parallel in the
sphere of neurology, as the following reference to Dr. Head’s address
indicates: “ When the great toe moves upwards and the inner ham¬
strings contract on scratching the sole of the foot, we can assume that
the normal activity of the pyramidal tract is disturbed ; but this sign
is no evidence of the existence of organic changes. It may be an
early indication of structural disease, or, on the other hand, a purely
transitory disorder of function, as, for example, after an epileptic
LX VI. 30

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452 OCCASIONAL NOTE. [Oct.,

convulsion. In both cases the reaction is identical, but its prognostic
significance is fundamentally different.”

Further light was shed upon the obscure problem of dementia
praecox by Sir Frederick Mott’s demonstration on his recent pathological
researches^ 1 ) These findings are of extreme significance and do much
to illuminate the clinical and psychological conceptions of the disorder.
It is only by intensive research from all angles that a truly biological
conception of dementia praecox can be formulated, and scarcely any
problem in medicine is deserving of more attention.

The further proceedings can here only be enumerated. Dr. T. A.
Ross opened a discussion on psychotherapy; Dr. Greenfield demon¬
strated sections of peripheral nerves at different stages of regeneration ;
Dr. Prideaux, psycho-galvanic reactions; Dr. Scripture, speech registra¬
tion in nervous disorder; Drs. Head and Riddock, sensory alterations in
the hand from cortical injuries ; and Dr. Buzzard and Dr. Greenfield,
the pathological changes in the nervous system in encephalitis
lethargica.

We feel that the subjects for discussion were particularly well chosen,
in that they afforded an opportunity for the discussion of broad
principles in relation to the intimately related subjects—insanity,
psychoneurosis and nervous disease. In this short survey we have
designedly hinted at the possible application of the principles indicated
by Dr. Head, in his opening address, to the problems of more immediate
interest to the psychiatrist, since we feel our conceptions are capable
of much illumination by the neurologist and that the problems of
personality have to be met in both neurological and psychiatric work.
It is abundantly evident that it is impossible for psychiatry to attain its
full development as a narrow specialty, and it must remain in closest
contact with work in other spheres of medical interest. Perhaps this
meeting may be regarded as the symbol of a changed atmosphere in
the attitude of the medical profession with respect to mental disorder. It
would certainly seem to indicate that the relative isolation from the
main current of medical thought, which has had such an unfavourable
influence upon the specialty with which this Journal is more immediately
concerned, is now fast becoming a thing of the past.

(') Vide Proc. Roy. Soc. Med., 1920, vol. xiii (Sect, of Psychiatry), pp. 25-63.

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REVIEWS.

453

Part II—Reviews.

Sa mm lung Kleiner Schriften zur Neurosenlehre (Collection of Short

Contributions to the Doctrine of the Neuroses). Fourth series.

ByS.FREUD. Leipzig and Vienna : Heller & Co., 1918. Pp.717.

The contest between the champions and the opponents of psycho¬
analysis apparently shows no signs of abating, although it may well be
that the last word will not lie with the extremists on either side. In
the meanwhile, without waiting for that harmonious solution, it cannot
be too often repeated that even those who have no intention and no
wish to become psycho-analysts cannot afford to neglect altogether to
obtain some direct knowledge of the work of the man who—whatever
may be thought of some of his present or former disciples—remains
the powerful originator of a highly remarkable revolutionary movement
in both morbid and normal psychology. To the end of such knowledge
none of Freud’s writings are so well adapted as the successive volumes
published under the above title. They are short, they are highly
varied, they frequently deal with fundamental problems, they are at
times interestingly personal, and they may usually be grasped without
too severe an intellectual effort. This latest series, a very substantial
volume, contains no fewer than thirty-two studies, dating from the years
1912 to 1918.

There are some for all tastes, though a few will only appeal to the
most specialised psycho-analyst. We find, for instance, “The Dis¬
position to Compulsive Neurosis,” “ A Case of Paranoia contradicting
the Psycho-analytic Theory,” “ The Transposition of Impulses in Anal
Eroticism,” “False Reminiscence in Psycho-analytic Work,” “The
Conception of the Unconscious,” “ Fairy Tales in Dreams," “ Mytho¬
logical Parallels to an Obsessional Idea,” three “Contributions to the
Psychology of the Love-life,” “ Grief and Melancholia,” six papers on
“ The Technique of Psycho-analysis,” “ The Motive of the Casket
Choice,” “On War and Death,” “A Childhood Recollection in Goethe’s
* Dichtung und Wahrheit,’” and so on, the final paper—the only
detailed case brought forward in the volume—being the “ History of
an Infantile Neurosis,” covering forty pages, here first published and
put forward as a fragmentary by-product in the psycho-analytic investi¬
gation of an adult case.

It is impossible here to touch on all of these papers, but a few may
be specially mentioned. The first, on the history of the psycho¬
analytic movement, the growth of Freud’s doctrines and his relations to
Adler and Jung, is, from the personal point of view, much the most
interesting in the volume; it was epitomised in this Journal when first
published in 1914. The second study is a valuable and comprehensive
discussion of narcissism and of the large place it has gradually
acquired in the psycho-analytic scheme, from being, before Freud
adopted it, simply an auto-erotic perversion, in which the subject
treated his own body as an object of sexual interest and admiration,
until it has finally become regarded in the psycho-analytic system as a
normal stage in the orderly sexual development of human beings
generally, “ no longer a perversion, but the libidinous complement to

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the egoism of the self-maintaining impulse which is the proper inheri¬
tance of every living creature.” The justification of the wider appli¬
cation of narcissism was first found in the need for a psycho-analytic
explanation of dementia pnecox (paraphrenia in Freud’s terminology).
Megalomania and aversion of interest from the outer world being taken
as fundamental traits of the paraphrenic, narcissism is regarded as
expressing the new aims and satisfaction of those impulses. It is
further argued that both among primitive peoples and among children
various traits may be noted which are to be considered an expression of
narcissism, which is viewed as distinct from auto-erotism, representing a
further stage of development, though the exact mode of defining the
difference is regarded by Freud as a difficult and delicate problem. He
points out two roads, however, by which he considers that the knowledge
of narcissism may be increased: (i) the study of hypochondria, and
(2) the consideration of the love-life of the sexes. Freud finds “ a
fragment of hypochondria in all neuroses,” and associates it with a
hypersensitive erogeneity which may be paralleled with narcissism. The
consideration of the normal sex-life leads to a more definite approach to
narcissism. There are two types of sexual attraction—that which is
based on the relation of the child to its mother or her protecting and
nourishing substitute, by Freud termed the leaning-type, and the more
perverted and often homosexual type, which finds its primary object, not
in the mother, but in its own person. “ It is in this observation that we
find the strongest of the motives which compel us to accept narcissism.”
We have thus to recognise that there are two primary sexual objects—
the person himself and the protecting woman—and we must accept the
possible primary narcissism of any individual, perhaps to become
eventually dominant in his object-choice. There is a difference, how¬
ever, to be recognised between men and women. While the boy at
puberty tends to transfer his primary over-valuation of self to his
sexual object, the girl at puberty, with the development of the latent
sexual organs, more frequently and perhaps in the most genuinely
feminine type shows an increase of the original narcissism, “with a
self-satisfaction in her bearing which compensates for her impaired
freedom in object-choice.” Such women love themselves w'ith the
same intensity that men love them ; they do not wish to love but to be
loved, and the man who fulfils this condition is the man who pleases
them. They are often highly attractive to men. But at the same time
much of the dissatisfaction of men in love, their doubts, their complaints
over the riddle of women, are caused by this feminine narcissism.
There are women, however, Freud adds, who love in the masculine
way, and, moreover, women are often delivered from narcissism by the
child which, being a part of their own bodies, is fitted to become an
object of love by natural transition.

The theme may be said to be continued in a later series of “ Contri¬
butions to the Psychology of the Love-life.” In the first of these a
special type of sexual choice in men is investigated. The man of this
type is impelled to make three demands as a condition for loving :
(r) there must be an injured third party—lover, husband, or friend;
(2) the beloved must not be pure and virginal, but approximate to the
courtesan and be always an object of jealousy; (3) he must be able to

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exercise an impulse to “ save ” her. This attitude is regarded as due to
infantile fixation of tenderness on the mother, even the desired courtesan
element being traced to the child’s discovery that his mother has led
that physical sex-life which he has been taught to look upon as low.
The next chapter deals with psychic impotence, which Freud regards
as so common as to be almost a trait of our civilisation. He connects
it with “ incestuous ” fixation of affection in childhood on the mother or
sister, arrest of development and consequentdisharmony of the tender and
sensual factors of love, leading to a tendency for the love impulse to go
out towards inferior objects. The chapter concludes with reflections on
the possibility that a high culture is unfavourable to the proper develop¬
ment of the love-life, and it is pointed out that the emotion in women
corresponding to psychic impotence is the demand for the stimulus of
the forbidden. The next chapter, which has an anthropological colour¬
ing, deals with the taboo of virginity,on the tendencyamong various people
to assign to some other person than the husband the first intercourse
with the wife. Freud considers that there really is a psychological
ground for this custom, and that a resistance to the sexual life in the
woman has to be overcome; there is not only the dread of pain but the
opposition offered by her narcissism to be overcome, so that sex
relations are apt at first to be for her a bitter deception. The husband,
therefore, was wise who assigned to a priest or other functionary the
duty of overcoming and diverting these reactions, which might otherwise
have brought unhappiness on himself.

Turning from normal psychology to psycho-pathology, we may note a
study of “Grief and Melancholia.” Just as the dream presents the
normal prototype of narcissistic psychic disturbances, so, Freud
argues, we may attempt to illuminate the nature of melancholia by
comparing it with normal grief. In grief it is the world which, by the
loss of some beloved object, has become poor and empty; in melan¬
cholia the loss is felt as having taken place in the ego itself, which
seems to have become unworthy. But if we listen patiently to the
manifold self-accusations of the melancholic, we cannot escape the
impression that they often do not fit the patient’s own person, but with
a little modification quite fairly fit some person whom he loves, has
loved, or ought to love. Investigation confirms this impression. So
we have in our hands the key to the picture presented by the disorder:
the self-accusations are reproaches really directed to the object and
turned against the patient’s own ego. The wife who loudly bewails the
fate of her husband bound to so unworthy a mate is really accusing her
husband of unworthiness, whatever may be its form. The process can
be reconstructed. There was a choice of object; love was bound
up with a particular person; by the influence of some mortification or
disillusion the object of love is shattered. The normal result, the
transfer of love to some other object, fails to follow, and the libido
withdraws into the ego. There an identification takes place with the
abandoned object, and the ego is judged as that object is judged. So
that instead of, as in grief, a loss in the object, there is a loss in the
ego. It would seem, Freud remarks in agreement with Rank, that the
object-choice originally took place on a narcissistic foundation, so that
when the shock of deception comes, there is a regression to narcissism,

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and the love-relation with the beloved object, in spite of the conflict,
still subsists in a new form. Identification is the preliminary stage
of object-choice and in its expression is ambivalent. There is a
desire to incorporate the beloved object, in the oral and canni¬
balistic phase, in a way corresponding to eating ; Freud agrees with
Abraham that thus must be explained the melancholic’s refusal of food.
The love-adaptation of the melancholic to its object has, however,
experienced a two-fold fate: it has partly regressed to identification,
but it has also partly returned, under the influence of an ambivalent
conflict, to the stage of sadism. It is this sadism which explains
the tendency of the melancholic to suicide. “ The analysis of melan¬
cholia teaches us that the ego can only kill itself when by the return of
the object-adaptation on to itself it regards itself as an object, and so
can direct its hostility against itself.” The most remarkable trait of
melancholia is its tendency to develop into mania, so that the analytic
explanation of melancholia must cover mania. That, Freud admits, is
not quite easy to effect. He cannot go beyond “ a first orientation.”
When one has succeeded by one stroke in releasing oneself from some
long-continued pressure there is a feeling of triumph. Mania is just
such a triumph, only the ego is unaware of what it has conquered and
why it triumphs. The manic person is demonstrating to us his freedom
from the object which has caused his suffering. This part of the
explanation Freud regards as not more than “ plausible,” but the whole
paper is a brilliant example of his virtuosity in devising a dynamic
mechanism for psycho-pathological states.

Some sections of the volume will appeal chiefly to the specialist
psycho-analytic reader. This is the case, for instance, with two papers
which form part of “Prolegomena to a Metapsychology,” meant to
clarify and deepen the theoretical assumptions beneath the psycho¬
analytic system. These papers are highly vague and abstract; they
make much play with the “ polarities ” and “ ambivalencies ” which
pleased the old German metaphysicians, and to many readers it will
probably seem, indeed, that (to parody Milton) the new metapsychology
is but the old metaphysics writ large. Freud himself seems to have had
a suspicion of this, for he has abandoned his original intention of
developing these papers into a volume. Other papers that appeal to
the specialist are the series of “ Further Counsels on Technique.”
There is here, however, much wise advice which may be appreciated by
many who are not psycho-analysts.

A paper that stands by itself is entitled “ Reflections on War and
Death ” (it has been translated by Dr. Brill, and published in a small
volume by Moffat, Yard & Co., of New York). Written in the midst of
the great conflict, it is a thoughtful discussion in a large though
psycho-analytic spirit of some of the problems raised by the war.
There is an absence throughout of any harsh, bitter or contemptuous
reference to the enemies of the author’s country. He retains his racial
internationalism (as it may be) unimpaired.

It has only been possible to touch on a few of the rich contents of
this large volume. The portions of the volume which remain are of at
least equal interest and value alike to the psychologist and the psycho¬
pathologist. Havelock Ellis.

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Mind and its Disorders: A Text-Book for Students and Practitioners of
Medicine. By W. H. B. Stoddart, M.D., F.R.C.P. London :
H. K. Lewis & Co., 1919. Third edition. Demy 8vo. Pp. 580.
With 81 illustrations. Price i8r. net.

In this new edition of his text-book Dr. Stoddart says he has
fundamentally changed his attitude towards mental disease, having
personally investigated very many patients by the psycho-analytic
method and thus been convinced of the truth of Freud’s doctrines.
He has endeavoured to indicate the psychical mechanisms underlying
the various maladies, and he has done this with a sense of proportion.

He is not one of those who think that the war has added much to
our knowledge of mental disorder. It has been responsible for a large
number of cases of functional nervous disease, and has thus stimulated
interest in and study of such maladies, but, so far as he is aware, none
of the war cases underwent a deep psycho-analysis.

He has revised his classification of mentai disorders, and has added
new chapters on the anxiety neurosis and paraphrenia.

In his chapter on general paralysis he expresses the opinion that the
treatment by intraspinal and intra-cranial injections of salvarsanised
serum and similar preparations has been overrated, but he gives an
extended account of these as well as other modern methods of treatment.

In view of some of the difficulties of regarding this disease as a mere
syphilis, he suggests that the spirochaete of general paralysis (and tabes
dorsalis) is specific, and that in spite of its biological resemblances to
that of syphilis the two are not identical. According to this view
general paralysis is a specific (venereal) disease, and general paralytics
who exhibit the ordinary manifestations of true syphilis must be regarded
as having contracted two separate specific diseases, viz., general paralysis
and syphilis.

In his account of the morbid anatomy of general paralysis some
points invite comment: (1) He says that “well-marked atheroma
aortae occurs in about 35 per cent, of the cases and slight atheroma or
endarteritis in about 45 per cent." This surely is an inadequate in¬
dication of the frequency of syphilitic aortitis in this disease. (2) Of
course he mentions granularity of the ependyma of the ventricles,
“best seen, when present, in the floor of the fourth ventricle”; but he
omits the important point about this. In a great variety of conditions
granularity is often found near the lateral angles: in this disease it is
most marked in the calamus. A granularity of this ventricle most
marked in the calamus is, of all the naked-eye morbid appearances in
general paralysis, the most constant, and this disease is practically the
only one in which it is found, at any rate in this country. (3) He says
that decortication on stripping the pia from the cerebrum is “absolutely
characteristic of a general paralytic brain, provided that the interval
between death and the autopsy is not much prolonged.” The state¬
ment requires considerable qualification. In other conditions decorti¬
cation is not very rare, apart from delay of the autopsy; and in some
cases of general paralysis it does not occur. Dr. Stoddart says nothing
about regional distribution of decortication; so though his book was,
in the first instance, designed to induce the reader to think neuro-
logically, it ignores the instructive variations of this distribution. A

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reference in this connection to Flechsig’s myelination diagrams would
have roused the student’s curiosity to useful purpose. (Incidentally, a
hint as to the neatest and easiest way of stripping a fresh hemisphere
would have been a useful addition; through inattention to the arterial
supply this little procedure is often bungled, and not by beginners only.)

Dr. Stoddart’s account of the aetiology and pathogenesis of general
paralysis is directed mainly to such considerations as he can adduce to
emphasise the importance of the part played by the spirochaete. Of the
difficulties of attributing the disease entirely to an infection, of whatever
sort, he points out only that there is no record of any asylum patho¬
logist or attendant on the insane having contracted general paralysis
from one of his patients.

But the book as a whole is by no means one-sided; and as Dr.
Stoddart has been at great pains to bring it once more in many ways up
to date, it has a wide sphere of assured usefulness.

Sydney J. Cole.

Military Psychiatry in Peace and War. ByC. Stanford Read, M.D.,
Lond., late Major R.A.M.C., Officer in Charge, “ D ” Block,
Netley. London : H. K. Lewis & Co., Ltd., 1920. Pp. vi + 168.
Price 1 or. 6 d. net.

As medical officer of “D ” Block, Netley, Dr. Stanford Read had an
exceptionally wide experience of acute mental cases. All the psychotic
cases occurring in the oversea troops passed through this hospital
before their disposal in various directions, and Dr. Read states that
from August, 1914, to May, 1919, the admissions amounted to 12,320,
of which 331 were officers and 11,989 N.C.Os. and men. This work
is chiefly based upon the study of 3.000 consecutive cases which were
admitted during the year 1917, and since the author states, “ I have
followed up their careers nearly twelve months later by visiting the
various war mental hospitals to which they had been transferred, and
have made statistical notes thereon,” it is apparent that this volume is
the product of very arduous work and research undertaken at a time
when the ordinary official routine must in itself have been exceptionally
heavy. The fact that Dr. Read has by this investigation been in a
position to supply data as to the end-results of his cases considerably
enhances the value of his book, especially as a similar opportunity is
unlikely to occur again for some time—or at least we may venture to
hope so.

The opening chapter in which the author deals with the psychology
of the soldier indicates the line of approach which he finds most
illuminating in the study of his clinical material. He furnishes an
excellent study of the influence of the war situation, with its new
demands and stressful experiences, on the personality of the new
recruit fresh from civilian life, and throughout the book his cases are
consistently presented in terms of reaction to environment, and he
endeavours to explain the various symptom-pictures—apart from the
frankly organic psychoses—as the product of mental conflicts and
psychogenetic factors. He develops the question of psychogenesis at
some length in relation to the “exhaustion psychoses,” and he suggests

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that the “ stress and strain ” factor—mental and physical exhaustion—
will not produce mental symptoms apart from other factors being
involved. He says, “ Continued war experience has only served to
undermine more and more the position of the so-called exhaustion
psychoses in psychiatric nosology,” and he indicates that while some
confusional states are toxic in origin, and associated with malaria,
sunstroke or dysentery, “ many confusions are undoubtedly psycho¬
logical in origin, such as those we see so commonly associated with
mental deficiency. Maladaptable mentalities, when called upon more
or less suddenly to face difficult and new situations, will naturally
react in a confusional way from conflict of impulses. At times what is
taken for confusion is really a dream state resulting from an inherent
desire to negate reality.” In dealing with paranoid states and alcoholic
psychoses, Dr. Read finds himself in agreement with the Freudian
viewpoint in relation to these types of disorder.

In discussing the wider aspects of the treatment of mental disorder
in the light of war experience we are glad that Dr. Read does not feel
called upon to make comparisons between the recovery-rate in war
mental hospitals and that of civilian asylums. Comparisons of this
kind are apt to be made, and they are not only unfair, but they are
necessarily unscientific. The clinical material in war hospitals was of
necessity much more favourable in respect to recovery than that found
in civilian hospitals, especially as many war cases were purely reactive
and the product of unusual stress, the removal of which readily
resulted in recovery.

We can thoroughly recommend this book, and while some of its
readers may not find themselves in complete agreement with all the
views of the author, they will certainly find in it much information of
value, and a particularly clear and concise presentation of the various
forms of mental disorder from the psychogenetic viewpoint.

H. Devine.

Some Adaptive Difficulties found in School Children. By Esther L.

Richards, M.D. (Mental Hygiene , April, 1920.)

Articles by various medical writers have appeared of late putting
forward a claim on the part of psychiatrists to exercise a wholesale
direction over the education of the young. Some of these articles,
being largely compounded of old familiar truths more or less
emasculated by translation into modern psychologists’ slang, together
with some assumptions of doubtful validity and a surfeit of advice to
educationists about things they understand at least as well as their
would-be instructors, appear ill calculated to persuade the public to
receive the psychiatrist into their homes or their schools, there perhaps
to exhale “ that most poisonous and degrading of all atmospheres—a
medical atmosphere.” Many of the failures and breakdowns of adult
life, no doubt, originate in a misguided upbringing in childhood, and
this the psychiatrist has particular reason to know; but supposing he is
let loose in our schools, will it tend to the general good ?

Dr. Richards’ modest paper is welcome, because it goes some little
way towards answering this question in terms of practical experience.

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Her work was undertaken at Dr. Adolf Meyer’s instigation. He had
suggested that a school physician with training in psycho-pathology
should attend regular conferences at which the management of
problematic pupils is brought up and discussed, and that the instances
calling for special study might then be taken up under the direction of
the physician, perhaps by a teacher detailed for part of her time to
make a study of the home situation and of all those facts which the
physician needs for a thorough study of the individual.

These ideas Dr. Richards has been applying practically, at Public
School 76, in the Locust Point district of Baltimore—a more or less
isolated industrial community, devoid of coloured inhabitants, but
largely of foreign extraction, and not uncommonly using the German,
Polish and Hungarian languages in its homes. School 76 contains
the majority of the children, enrolling about 800. Housed in a
dilapidated building on the edge of a waste, not only has this school
gradually come to be a sort of community centre for the Point and a
beacon among the public schools of the city, but its achievements are
not unknown to many people in other parts of the country. It is not
the school “ bank,” the classes for backward, defective, and tuberculous
children, or even the full blooded Parents-Teachers’ Association that
are so worthy of comment as is the fact that this school is peculiarly
identified with the community from which it springs. Besides
recognising the children’s need of adequate opportunities for play, for
self-expression through vocational training, music, school plays, etc,
and for healthy amusement from clean, stimulating picture films, it
recognises the parents’ need of encouragement and guidance in the
out-of-school problems of home environment and growth, as w r ell as
their need of understanding and helpful discussion of domestic anxieties
and financial struggles.

The fifteen school months during which Dr. Richards’ study was
made were interrupted by three enforced school holidays of from two to
eight weeks each, due to the influenza epidemic, the freezing and
bursting of pipes, and finally the burning of the main building itself,
with a consequent scattering of the children for temporary accommoda¬
tion in other schools. These circumstances, and the fact that only two
days a week could be given to the work, may, she says, “ serve to
comfort those who mourn that only forty-six children were seen during
the above period.”

She devoted the first few weeks to a leisurely acquaintance with her
new environment. There was no room-to-room canvass for difficulties
of adaptation, or any other concerted activity. She strove to drive
home the idea that she had not come to teach, nor yet to offer a new
programme of reform, but merely to learn whether or not one accus¬
tomed to studying sources of failure in individual human beings could
be of any help there. “ And,” she asks, “ what better way to answer
this query and swing into the tide of school life than by drifting into
class-rooms, enjoying their wealth of activities and reactions, and listening
to the stories of teachers who bear the burden and heat of the day ? ”

We know that “drifting in,” distracting both teacher and taught. It
is as if someone should ask to be present at a proposal of marriage, to
see how it is done. However, Dr. Richards tells us that before long

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her question box in the principal’s office contained more requests for
suggestions with regard to specific children than it was possible to
compass. Of the forty-six children who came under observation,
thirty-five were reported as having difficulty in keeping up with their
grade in one or more subjects. Binet-Simon tests showed sixteen of
these to have a mental retardation of from three to six years ; and the
academic troubles of the other nineteen were associated with, if not the
disguised expression of, such faulty psycho-biological reactions as
shyness, laziness, inattention, vicious tendencies, sensitiveness to
criticism, day-dreaming, hypochondriacal fears with resulting irregular
attendance. The eleven remaining from the total forty-six were referred
for the more overt adaptive difficulties of tantrums, sullenness, crying
spells, twitching, indifference, excitability, poor coordination with the
hands, quarrelsomeness, etc.

In fourteen pages of tables Dr. Richards presents notes of all the
forty-six cases. These notes provide not only school information, but
valuable details of home life and out-of-school habits. The last two
columns give her suggested modifications, and notes on the subsequent
course. In fourteen of the cases she does not appear to have ventured
any suggestions. In only two instances do her suggestions contain
anything recognisable as medical advice, one being a case in which she
suggested a Wassermann test, and the other a case in which she
prescribed bromides and Fowler’s solution. In the remaining cases
her suggestions—eminently sensible, as far as we can judge—are such
as could have been made, and indeed not uncommonly are made, by
experienced school teachers who yet know nothing of psycho-pathology
as it presents itself to the medical mind. Similarly, the case-notes
contain none of the psycho-pathologist’s jargon, and, except as regards
the Binet-Simon tests, do not indicate the employment of any special
technique. Did Dr. Richards, then, leave her psycho-pathology in the
umbrella-stand in the hall ? At any rate, she seems to have exercised
a good deal of instinctive wisdom ; and her paper, with its plain state¬
ments of fact and its impartial presentation of the whole of the case
material, deserves minute study. Sydney J. Cole.

The British Journal of Psychology , Monograph Supplement VI —
Pleasure — Unpleasure: An Experimental Investigation on the
Feeling-elements. By A. Wohlgemuth, D.Sc.Lond. Cambridge
University Press. Royal 8vo. Pp. 252. Price 14X.

This monograph opens with an interesting rlsunii of the opinions
of various authors on the subject of “ feeling,” in which the lack of
uniformity in connection with the whole matter is apparent. The
author states the various differences of opinion requiring settlement, and
ends his introduction by giving his reasons for his preference for the
introspection method in experimental work. The second part, which is
experimental, gives exact details of the nature of his laboratory work.
Four trained observers offered their services, and in Part III, headed
“ Protocols? each experiment is given in full. This part occupies 140
pages, and the records are there for others to form their conclusions.
Part IV gives the results of the experiments, and in Part V these results

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are summarised. The conclusions reached are embodied in 77 rules,
and it is obviously impossible to deal with these in the present instance
in any adequate manner. It is of interest to note that the author states
that there are only two qualities of feeling elements, viz., pleasure and
unpleasure, that unlike feeling-elements may co-exist in consciousness,
and that opposite feeling-elements may fuse, sometimes tending to
mutual neutralisation and sometimes without any neutralisation,
producing in the latter case a “ mixed feeling.” To those interested in
psychology this work will prove a veritable gold-mine so far as results
can be obtained from introspection, and the author is to be congratulated
on the manner in which he has summarised the mass of evidence
obtained from his painstaking and careful experimental work. He
expresses the hope that similar research may be conducted in pathological
cases, and with this we cordially agree. R. H. Steen.

Psychotherapie. By Dr. Andre-Thomas. Paris : Bailliere & Fils,
1912. 8vo. Pp. 519. 12 frs.

This is one of twenty-eight volumes which constitute the Therapeutic
Library, edited by Profs. A. Gilbert and P. Carnot. After a short
preface by Prof. Dejerine and an introduction comes Part I, wherein
the different methods used in psycho-therapy are described. In the
first chapter of this part a complete account is given of suggestion in
the waking state, hypnotism and auto-suggestion. The psycho¬
analysis of Freud is mentioned under the heading of “methods derived
from hypnotism and suggestion ”—a position which will be strongly
resented by most psycho-analysts. Only four pages are allotted to this
subject as compared with forty devoted to suggestion. Chapter II
deals with persuasion in its rational, sentimental, religious and
philosophic aspects. The next chapter discusses treatment by isolation.

The second part is devoted to the maladies in which psycho therapy
may be employed and the most useful methods in each case. It
includes in a first section hysteria and neurasthenia and in a second
section “ mental ” maladies, which would seem to imply that the author
does not consider hysteria a mental disorder. In the third section the
treatment of organic diseases of the nervous system is dealt with.

The book is closely printed and contains an immense amount of
information on the subject—in fact it is more of an encyclopaedia than
a text-book. It were easy to criticise certain pages adversely—for
example, the chapter on the treatment of obsessions, which adds little
to our knowledge of the subject; and there are other parts in which
the opinions expressed seem a trifle out of date. But it must be
remembered that this publication first saw the light in 1912. At this
time general medical opinion regarding psycho-therapy was less tolerant
in its attitude than is the case to-day and in reality the writer was well
in advance of his time.

Taking the volume as a whole our congratulations are due to
Dr. Andr^-Thomas for so successfully fulfilling his task, and for his
industry in collecting so large a body of knowledge and presenting it
in so easily accessible a form. We can only hope that a second
edition will soon be called for, when the experience gained in the war
can be embodied in the text.

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La Psycho-analyse des Nevroses el des Psychoses. By E. Regis and
A. Hesnard. Paris: Felix Alcan. Pp. xii + 384. Price
3 A- 5°-

It would appear that the extension of the doctrine of psycho-analysis
has not been so marked in France as in certain other countries. One
of the reasons for this is the multiplicity of literature dealing with the
subject and the difficulty experienced by the reader in understanding
this colossal work by the aid of these very diverse publications, in the
midst of which the principles of the doctrine lie scattered here and
there. It must also be remembered that France is a Latin country and
that all Freud’s works are written in German ; moreover, it is a well-
known fact that Freud is not easy to understand, even for the expert
in German.

In producing this book the authors had the following objects in view :
(1) the translation of the fundamental principles of psycho-analysis into
the French language, and (2) the introduction of light and harmony into
the midst of this rather clumsy assemblage of ingenious and anomalous
hypotheses.

The first part of the work contains, amongst others, chapters dealing
with the dynamic theory, the sexual theory and the different methods of
exploring the unconscious mentation, viz., (i) the interpretation of
dreams, (ii) free association, (iii) the word-association experiment, and
(iv) the investigation of the errors and slips of every-day life. The
second part principally deals with the psycho analytic methods as applied
to the neuroses and the psychoses, and with criticisms of the psycho¬
analytic treatment.

The book is, above all, a clear and concise exposition of the Freudian
doctrine. A welcome feature is the lucid manner in which the technique
is described; this subject, all too often, receives but scant attention by
the majority of writers. In the chapter on dreams the theory of
“ regression ” is rendered especially clear. Frequent use is made of
Bleuler’s expressive term “ Pansexualism,” which is employed to denote
Freud’s doctrine of the sexual instinct as the source of all psychic activity.

Prof. Rdgis and Dr. Hesnard being psychiatrists, their chapter on
the application of psycho-analysis to the psychoses is particularly
interesting. They point out that the treatment has had some degree
of success in dementia praecox and paranoia, and they believe that its
usefulness is capable of considerable extension in the domain of the
other psychoses. Maeder, of the Zurich school, is quoted as saying
the insane patient is the most suitable subject for psychological analysis,
being, in spite of appearances, less inaccessible than the “ neuropath ”
because he is more docile and more ready to confide in the doctor
when the latter knows how to understand him. The Zurich doctors
claim that they have brought about the amelioration of several of their
insane patients, particularly those of the dementia praecox form of
insanity. The absence of an index is somewhat disappointing, but a
full “Table of Contents” and a highly systematic arrangement of the
reading matter compensate to a great extent for this deficiency. The
usefulness of this little book is enhanced by the inclusion of an
appendix on the copious literature published in different countries on
the subject. Norman R. Phillips.

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Part III.—Epitome of Current Literature.

1. Psycho-Pathology.

An Account of the Witch Craze in Salem, with reference to some Modern

Witch Crazes. {Arch, of Neur. and Psychiat., May , 1920.)

Potts, C. S.

In this Presidential Address to the Philadelphia Psychiatric Society,
Potts recounts in considerable detail the story of the epidemic of
accusations for witchcraft in Salem, Mass., in 1692. The craze began
in the home of the Rev. S. Parris, pastor of the village church. His
family consisted of a daughter, aged 9, a niece, aged 11, and a
servant, Tituba, who was half Indian and half negro. Associated with
these were four other girls, some of them belonging to prominent
families. For purposes of amusement, Tituba, who had come from the
West Indies, used to practise tricks and incantations common among
the natives of her home. During these performances they did strange
and unusual things, such as getting into holes, creeping under chairs,
performing various antics and uttering ridiculous speeches. While it is
natural for children to do such things more or less, they were not
countenanced by their Puritan relatives and masters. Great, therefore,
was the consternation when they learned of it. Dr. Griggs, the village
physician, whose niece was one of the participants, was called, and not
being able to make a diagnosis, he said, “ They are possessed of the
devil or bewitched.” This, being noised about, caused the children to
become objects of curiosity, which made them show off more. Mr.
Parris called a meeting of ministers of the neighbourhood, who, after
investigating and praying, unanimously concurred in the doctor’s
opinion. The supposed victims, threatened with severe discipline if they
did not tell who had bewitched them, finally accused Tituba and two
feeble old women. This was the beginning of a wholesale persecution.
In four months two hundred and fifty persons were accused and put in
gaol—no small percentage of the population. Nineteen of them were
hanged and their property confiscated; two died in prison from bad
treatment; one was tortured to death. Ultimately public opinion
revolted, and in May, 1693, Governor Phips issued a proclamation
releasing from custody all persons—about a hundred and fifty—held on
the charge.

As to the psychology of the outbreak, Potts considers it was due to
hysteria, fomented by religious fanaticism and lying, some of it possibly
of the pathological type, but most of it malicious. The Puritans were
a fanatical and bigoted people, who persecuted vigorously all who did
not agree with their religious convictions, and this in spite of the fact
that they themselves had come to America to escape religious perse¬
cution. But for the persecution of heretics, there would probably have
been no persecution of witches. These people led a repressed life, and
were therefore ripe for any orgy when the opportunity came.

A number of symptoms of hysteria were present. The influence of
suggestion and the morbid desire for notoriety are apparent. Mimicry
was frequent. Some had areas of anaesthesia or hyperaesthesia. These

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symptoms were encouraged maliciously by older people. Begun by
young girls who at first thought of nothing more than being pitied and
indulged, the fraud was continued by adult persons who were afraid of
being accused themselves. It is noteworthy that many of the accused
had had difficulties with their neighbours.

It might be supposed that such a thing could not occur to-day.
Potts believes that it is not only possible, but to a certain extent is
already occurring. The uproar at the Salem trials reminds him of the
newspaper accounts of the hearing on the question of Sunday music in
Philadelphia before a committee of the legislature, when speakers in
favour of the measure were hissed, vilified, and their voices drowned in
the uproar made by their opponents, largely composed of clergymen.
Potts says, “ We are now suffering from a surfeit of legislation and
proposed legislation regulating our habits, our business—in fact,
practically everything good or bad that a person is liable to do.” This
State forbids playing any game of cards in a public resort. That one
forbids buying a cigar on Sunday. A number have gravely dealt with
the portentous question of giving tips. Every winter produces a sheaf
of bills to regulate women’s dress. Where the law requires a washer¬
woman’s cook-stove to be assessed, and a millionaire’s wife’s diamonds
are not assessed, the legislature is deeply engaged with the censorship
of moving pictures. Where mob murders are a well recognised
institution, the legislature is passing an act to regulate the length of
hat-pins. A special target for legislative suppression is anything which
may add to the pleasure and relaxation of the individual. Innumerable
societies exist whose mission it is to regulate public and private
institutions, private business, education—in fact, nothing escapes.
Many of these organisations and individuals who are ambitious to have
the world run according to their ideas, in order to gain their ends are
guilty of false and reckless statements, of advocating the confiscation of
legally owned property, of breaking laws themselves in order to capture
those who in their opinion are breaking laws, and of vilifying and
slandering those opposed to them. In all these ways they resemble
those who prosecuted the Salem witches. A still more serious thing is
that those whose duty it is to enforce the law engage in orgies of
persecution in which people’s rights are trampled on with impunity.
In Newark, N.J., not long ago, policewomen were ordered to forcibly
wash the faces of any girls on the street with painted cheeks, and to
have them photographed as vampires. In New York, in 1918, a wave
of hysterical morality caused the raiding of public hotels, apartment
houses, restaurants and billiard rooms, with the arresting, without
warrants, of 1,100 people. All this to find possible hidden vice.
During the war, tavern keepers who had paid a license and whose
capital was invested in their business were compelled to close without
compensation, when located within certain prescribed areas. Tobacco
is at present in serious danger of execution for witchcraft. In a
number of States the sale, and even the smoking, of cigarettes is
unlawful; in Kansas, newspapers and magazines advertising them
cannot be publicly sold. It will be found that most lynchings and
other outbreaks of mob violence occur in States most prone to freak
legislation. One of the results of the peculiar state of mind now

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afflicting so many of the author’s compatriots is the meddling with the
management of institutions such as prisons and hospitals for the insane.
The officials of these institutions are very much in the position of the
Salem witches.

Much is done now in the name of law, order, and progress that is not
sane. The various crazes of to-day are an evidence of the unsettled
minds of the community. They are therefore legitimate subjects for
the attention of psychiatrists. Not a little of freak legislation is
proposed by medical men, which makes it doubly important that we, as
medical men and women who study especially mental diseases, should
endeavour to guide such minds, both medical and lay, into proper
channels. Sydney J. Cole.

2. Clinical Psychiatry.

Dementia Prcecox in Twins. [Demence precosegBnellaire.\ (Z’ Encephale,
April , 1920.) Laignel-Lavastine and Boutet.

Twin sisters, set. 37, were admitted at the same time into Sainte-
Anne’s Asylum in 1913 ; the diagnosis then made, viz., “ folie & deux,”
was, in the opinion of the authors, justifiable at first. One of the
sisters, G., considered to be the active element in the “ folie il deux,”
was the first to start delusions of persecution with false interpretations,
and then auditory hallucinations; the other sister, B., developed
delusions later. No sooner was G. transferred to another asylum than
B., who was regarded as the passive element in the “folie h. deux,”
recovered, or apparently recovered. Thus the first diagnosis seemed
to be confirmed, but this did not take into account the subsequent
course of the cases.

G. remained under certificates from 1913 until February, 1920, when
she died of pneumonia. According to the last report made of her case,
there was undoubted mental deterioration, but all the psychic functions
were not equally affected; thus, though memory and ideation remained
good, and attention was fairly well preserved, both the emotions and
the reactions were much impaired. Indifference was the predominant
feature of the case—she took no interest in anything, she was neglectful
of her appearance, and completely inactive; she had various absurd
delusions as well as hallucinations, but she showed no anxiety nor any
violent reactions. It became quite clear that this was a case of
dementia praecox.

B., though discharged from the asylum within three weeks of her
admission in 1913, continued to be more or less deficient—in the
words of a reliable informant: “ She has never been quite normal
since.” In November, 1919, she was again brought to the asylum,
where she still remains; the following symptoms—negativism, manner¬
isms, emotional indifference and inactivity—undoubtedly point, in her
case also, to dementia praecox.

It is thus seen that the original diagnosis of “folie £ deux” finally
resolved itself into one of “ dementia praecox in twins.” Laignel-
Lavastine, in a recent paper, insisted on the importance of recognising
this particular variety of “ familial dementia praecox,” which was
originally described by Soukhanoff.

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In the discussion which followed, Dr. Arnaud described two exactly
similar cases, which he and Dr. Pierre Janet have had under observation
now for several years. It was likewise a question of twin sisters, who
became afflicted at the same time with a syndrome consisting of a
considerable impairment of affectivity, and also of volition, without any
marked enfeeblement of the intellectual faculties at first. The principal
characteristic of the one is apathy, and of the other, inertia. In short,
both are cases of dementia praecox.

Dr. Laignel-Lavastine said that Dr. Arnaud’s cases furnished yet
another example of dementia pnecox in twins, to be added to those
cases of familial dementia praecox already recorded.

Norman R. Phillips.

Nervous and Mental Disorders of Soldiers. (The Amer. fount, of Ins.,
April, 1920.) Brown, Sanger.

An account is given of the administration of Base Hospital 8, where all
cases, except those evacuated through England, were grouped for return
to the United States. Some 6,093 cases passed through this hospital
up to March 1st, 1918. They were grouped under the following head¬
ings: psychoses, 1,916; psycho-neuroses, 1,663; epilepsy, 752; con¬
stitutional psychopathic states, 634; mental deficiency, 524; organic
nervous disease, 148.

Psychosis : An unusual type of reaction was met with and was referred
to as “ war psychosis.” This reaction was met with in about one-fifth of all
the cases. On admission these patients were bewildered, disorientated,
inaccessible, and showed clouding of consciousness. There were active
hallucinations of sight and hearing. They generally thought themselves
at the front under fire and were anxious and apprehensive. This
condition had some features in common with the psycho-neuroses, but
the condition differed in that the patients were inaccessible and
disorientated, with mood changes and no insight. Emotion and excite¬
ment seemed to play a prominent part in its production. The impression
was that the prognosis was good. Another group resembles this in
some respects. As a rule the patients had not been to the front. They
were confused, rambling, disorientated, and presented the picture of
delirium. The condition was regarded as one of hysterical delirium.
Some cases of dementia praecox gave a history of symptoms previous
to enlistment, others appeared to develop since. Depression was
more commonly met with than elation in manic-depressives. Both
showed a war colouring. Psycho-neuroses: These cases must be fully
understood to be successfully treated, and the fact that they are
disorders of the mind and not of the body must be fully appreciated.
Two general types were recognized, those of ordinary civil-life t>pe and
those resulting from battle experiences. The former rarely reached
the front. A number of cases of mental deficiency, epilepsy, and
mental disease exhibited war neuroses, such as mutism, tremors or
hysterical hemiplegia. Epilepsy: The constitutional make-up of the
epileptic is of greater significance than the actual seizure. The disease
should be interpreted as a severe degenerative neurosis, of which the
seizure is not the most important symptom. Cases of epileptic equivalents
were common. The Amnesias : A number of these were really cases of
LXVI. 31

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epilepsy, others occurred after excessive use of alcohol, and others were
hysterical in nature. The hysterical individual escaped from a difficult
or intolerable situation by wiping out from memory all circumstances
associated with it. Constitutional psychopathic states : These patients,
while not suffering from frank mental disease, nevertheless were in a
mental condition sufficiently abnormal to bring them into serious
conflict with those about them. Some of these people might have
made fair progress in civil life where they could have changed their
environment, but in military service this was not possible. Mental
deficiency : Many of the defectives were useful in labour battalions.
Their emotional make-up and conduct were considered of more impor¬
tance than the testing of their mental ages by scale. Organic nervous
diseases: Peripheral neuritis after diphtheria, influenza or other toxic
condition was frequently encountered. Syphilis of the C.N.S. was
found in many cases, although comparatively few cases of general
paralysis or tabes were observed. A number of patients presented
mental symptoms or epileptiform seizures as the result of brain injury.
Encephalitis: Symptoms of an epidemic encephalitis are given, which
are very similar to those found in “lethargic encephalitis” of French
and British writers. These patients, however, were not particularly dull
and lethargic, and ptosis was not found as constantly.

C. W. Forsyth.

The Rehabilitation in the Community of Patients paroled from
Institutions for the Insane. (The Atner. fourn. of Ins.,
fanuary , 1919.) Clark , S. JV.

The rehabilitation of patients must begin in the Mental Hospital.
Information should be obtained in regard to the make-up of the
individual and to the situations faced which led to the disturbance of
behaviour. The patient should be fitted for active life by advice,
instruction and habit formation. Patients after discharge should only
be required to meet situations to which they can adequately react and
to which they can make good adjustments. The apparent disinclina¬
tions of the improved dementia praecox are actually preservative, and
he should not be asked to assume characteristics—the bearing of
responsibility, a tendency to compete normally with others, etc.—
which are absent. The patient must, however, be stimulated to some
extent, otherwise progressive disinterest in the environment is apt to
result. Each case must be treated as a distinct problem, but the
general principles outlined must be kept in mind. On discharge some
organisation—an out-patient department—should be available to
carry out supervision. This should include a medical director, an
examining division, a social service department, and, if desired, an
occupation bureau. The medical director should co-ordinate the work
of the department. The examining division would consist of medical
men trained in psychiatry. The physician should advise the patient
with regard to his activities, and watch for evidences, such as irritability,
depression, insomnia, functional pain, etc., that he is finding difficulty
in meeting the situation adequately. If unusual problems arise an
attempt should be made to aid him to weather the storm. The work
of the social service department ought to include investigation of the

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conditions of the patient’s home before discharge. If necessary the
members of the family ought to be educated in the understanding of
the disorder and of the factors which might cause future attacks.
Occasionally it may seem unwise to return the patient to his former
home. The social life, recreation, and avocations should be considered
with the aim of directing as far as is possible the activities of the patient.
The experiences and preference of the patient must be weighed in the
choice of employment. There is the question of control of the patient.
Parole should be granted with the understanding that he should visit
the out-patient department and abide by the advice given there. Our
aim should be to aid the patient in arriving at an understanding of his
limitations so that he will attempt only those activities to which he may
continuously react safely. C. W. Forsyth.

A Case of Myxademaious Psychosis.—Clinical and Pathological Report.

{Arch, of Neurol, and Psychiat., March, 1920.) Uyematsu , S.

The principal clinical features in this case were: vertigo, Rombergism,
disturbance of co-ordination, diminution of reflexes, general oedema,
arterio-sclerosis, sparseness of hair, bradycardia and slow respiration.
Mentally, there was depression, dulness, apathy, lack of emotional
reaction, somnolence, thickness of speech, and disorientation in time.
Post-mortem, the thyroid gland was atrophied, with lymph-cell infiltration,
and the isthmus was absent. The parathyroids could not be identified.
The pituitary body was small. Right oophorectomy had been performed
and there was chronic left ovaritis. The brain and cerebellum were
irregularly atrophied and oedematous. Arteriosclerosis and general
senile changes were present and a variety of cell changes were observed,
the most noticeable being vacuolation, which was considered patho¬
gnomonic.

The author attributes the senile changes present to the effect of
hypothyroidism, and considers that there may be some retiological
relationship between the congenital factor of absence of the thyroid
isthmus and this disease. Disease of the ovaries is suggested
as another tetiological factor, this condition having been found in a
previous case. There is a possible correlation between atrophy of the
cerebellum and the clinical symptoms of disturbance of co-ordination
and vertigo. F. E. Stokes.

3. Treatment of Insanity.

The Care of Sane Epileptic Children. (.Brochure pub. by John Bale,
Sons Danielsson, Ltd., 1920.) Fox, J. Tylor.

The writer discusses some aspects of the treatment and general care
of sane epileptic children in a residential colony, and records some of
his impressions and observations as Medical Superintendent of the
Colony at Lingfield. Out of over 330 epileptics there, 167 have not
yet reached their sixteenth birthday. These are housed in six separate
homes; there is a hospital for serious illness, a school building with
extensive gardens, and a central hall or chapel. The cases are selected
from a large number of applicants, but the only ground of rejection is

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feeble mindedness of such a degree that the child is not likely to benefit
by the education provided.

The majority of English homes are unsuitable for epileptic children
to live in. The epileptic, especially if he shows mental peculiarities, is
regarded by the household as abnormal, and the regard of others has
its subjective effect. The parents, to avoid trouble and anxiety, tend to
keep the child indoors, to the detriment of his health. Often they
themselves are mentally abnormal, and unfit for the care of their
epileptic offspring. In life on a colony, fits are accepted as ordinary
occurrences, physical dangers are readily guarded against, and adequate
supervision by day and night is assured. An outdoor life, open
windows, daily baths and a suitable diet are accepted essentials.
Success of the scheme depends chiefly on the character of the staff who
come in daily contact with the patients. Those who are successful
with epileptic children are born, not made. Nursing experience and
educational training may supplement, but cannot supply what is not
there.

The most cogent objection to colony treatment is the elimination of
family intimacy from the child’s life. Dr. Fox thinks this objection
probably less serious for epileptics than for most children. Partly to
meet it by reducing the size of the home units of the colony would
entail a very large staff. It might be mitigated by frequent holidays at
home, but these often lead to recurrence or increase of fits, and in any
case interfere with the rhythm so important in the epileptic environment.

The accommodation of adult epileptics on the same colony as
children has the serious drawback that the children may perceive the
progressive mental deterioration of many of the older patients, and,
realising the possibility of the same fate for themselves, may carry
about with them a continual apprehensiveness that is one of the very
worst possessions for an epileptic.

The school education of the epileptic child should be designed to
avoid mental strain, and to facilitate concentration by means of move¬
ment and sensory impressions. Manual occupation is therefore
indicated, and the best form of it is gardening. As an aid to mental
development, ambidextrous work has yielded encouraging results. A
foundation principle of treatment is inhibition through rhythm (regu¬
larity of hours, rhythmic drill, dancing, singing). Except in those rare
cases in which surgical interference may cure, there is no specific treat¬
ment. The value of drugs is uncertain ; and in some cases it may not
always be desirable to control the fits.

Some of the good results of colony life are seen in the diminution in
the number of fits. In the year after admission, 16 percent, of the
children have had no fits ; in the following year 30 per cent .; in the
third year 34 per cent. ; and in the fourth year 36 per cent. Control of
fits is most likely to be effected in those cases whose fits have begun in
the first, second or third year of life. Mental development is less easy
to report upon. Dr. Fox tabulates results of Binet-Simon tests,
showing the average mental age to be about a year behind the physical,
but points out that these tests are apt to be fallacious, as, even
independently of fits, the mental condition of epileptics varies so much
from time to time.

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At present the colony is mainly used for children whose presence in
ordinary schools is undesirable. The most favourable period for
arresting these children’s fits is already past. The colony should be
primarily a place for treatment; cases with few fits or fits of recent
onset should have precedence in admission. Sydney J. Cole.

4. Sociology.

Some Notes on Asexualisation, with a Report of Eighteen Cases. (J ourn.
of Nerv. and Ment. Dis ., March , 1920.) Barr , Martin IV.

Asexualisation has been practised from early times. It is mentioned
in the ancient histories of Rome and Greece, and has continued in
various races down to the present day. Mental defectives are known
to reproduce their kind rapidly, and they have so multiplied as to
become a distinct race, and as such need protection for themselves, and
the world from them, as they are a menace to society.

It is estimated that there are at least 350,000 mental defectives in
the U.S.A.—over 40,000 of whom are cared for in institutions—and it
is probable that 50 per cent, of the prostitutes are feeble-minded.
Asexualisation contributes to a quieting of nervous and exaggerated
emotional excitation, combats prostitution, and insures “race better¬
ment” by diminishing the defective. Thirteen States in America have
now legalised the asexualisation of imbeciles, criminals, and rapists.
Castration and oophorectomy are preferable to vasectomy and fellec-
tomy. The writer quotes eighteen cases, showing in practically every
case a definite improvement mentally and morally following operation.
There was a modification of vicious traits, leading to more tractability,
diminution of sexual desire and of uncontrollable temper, and the
subject became a fairly useful unit of society. F. E. Stokes.

(1) Psychiatric Annexes and Special Therapeutic Sections for Abnormal

Mental Cases in the Prisons. [Annexes psychiatriques et sections
thlrapeutiques splciales pour anormaux men faux dans les prisons. ]
Higer-Gilbert and Vervaeck.

(2) Psychiatric Annexes in the Prisons. [Les Annexes psychiatriques dans

les prisons .] (Bull. Soc. M'cd. Ment. de Belg., February, 1920.)
Duchateau and Masoin.

In view of the prominent part played by Belgium in the past with
regard to prison reform, these papers, read before tbe Belgian Society
of Mental Medicine, are of considerable interest.

The first paper expresses the views of Drs. H^ger-Gilbert and
Vervaeck, who have long advocated the formation of “prison-asylums,”
but in consequence of the opposition which these proposals have
hitherto met at the hands of the prison administrations, they suggest,
as a first step, the institution of psychiatric annexes in the large prison
centres: in other words, they propose the creation of a psychiatric
infirmary in one wing of the prison.

The ever-increasing number of recidivists, together with the results
of anthropological researches in the prisons, prove that the present
method of treatment of criminals is imperfect, and that the time has

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come to alter with discretion, but without scruple, the present code
which has been in existence since the last century.

It is an error, not only from the social but also from the scientific
point of view, to attempt to treat all delinquents in the same manner—
normal as well as defective, neuropath and morally obtuse. In fact, it
is this same error which explains, partly at any rate, the failure of the
prison system of to-day.

It is surely not just that the mentally affected should be submitted
to the same prison regime as the delinquents of normal intelligence
nor is it reasonable to expect both these types to react in the same
way to the mental treatment (persuasion, moral re-education, etc.).

Now, if the punishment, the prison regime, and the pedagogic and
moral treatment should be individualised in order to be efficacious; if
it is indispensable to adapt them to the type of mentality and of
biological abnormality of the prisoners ; it is surely necessary to reform
the whole system of the repression of faults on new principles, and to
bring them into harmony with the results of the researches of criminal
anthropology.

Heger-Gilbert and Vervaeck then point out how they would solve,
this delicate problem. Rather than be accused of being revolutionary
they propose a gradual and progressive reform of the prison system, at
the same time respecting, as far as possible, the framework of the old
cell system.

They demand three things—

(1) The re-establishment of periodical mental inspections of prisons,
which should be conducted by prison alienists.

(2) The creation of psychiatric annexes in the larger prisons, where
the accused under mental supervision, and the condemned suspected
of simulation, or of feeble mindedness, might be observed under better
conditions than is at present possible. Moreover, suitable accommo¬
dation should be provided for the treatment, under modern asylum
conditions, of those prisoners suffering from curable mental affections—
e.g., those resulting from toxic invasion—whom the law necessitates
keeping in prison.

(3) The organisation of special prison sections for the abnormal,
where the latter might be under better observation and scientifically
treated. For instance, those suffering from moral insanity, perverted
instincts, kleptomania, or abnormal sexual impulses, would be much
more suitably placed in one of these special sections than in asylums
whence they are discharged, as a rule, much too soon. The authors
maintain that it is not logical to send such cases to an asylum simply
because they are declared irresponsible from the penal point of view.

The treatment recommended for these abnormal cases is mental
and moral re-education, with the object of adapting them to social
life, in so far as that is possible. They should also be classified, so as
not to return to the community morbid individuals who would be a
constant source of danger to it. Only the genuinely insane should be
removed to asylums.

The doctor engaged in the prison service should be sufficiently
remunerated to enable him to devote all his energies to the study of
problems of criminology. He should have acquired a knowledge of

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psychiatry and anthropology, which would enable him to discover the
determining factors and the biological origins of the acts judged to be
unlawful, and to apply that method of treatment best calculated to
remedy the defects found, whether congenital or acquired.

Moreover, the psychological study of the delinquent will enable
the doctor, with the aid of the administration, eventually to decide on
the most suitable method of correction. With regard to this latter
point the authors are convinced of the great importance of work—not
the kind of work which has been in existence since 1839, and which
consists of making paper bags; but such as would raise the morale
and dignity of the worker. Two principles are maintained: (1) each
man ought to earn his daily bread, and (2) each man ought to be
paid for his work. The necessary equipment should be placed at the
disposal of the worker, to enable him to produce a well-finished article,
and, in the case of want of aptitude, he might be taught. The work
done should be paid for at its market value, portions of the sums gained
going respectively to the State, the victim and his dependants, and the
prisoner’s family ; or, where this does not apply, the money saved would
go to make up a small sum which would enable the delinquent to live
on being discharged from prison whilst awaiting employment; lastly,
a fourth part will enable the prisoner to buy extra rations at the prison
canteen. Much is expected from the last-mentioned item as an
incentive to work. It is understood that the delinquent capable of
work should only receive from the State the strictest minimum of
rations necessary for his subsistence, but he could considerably augment
the quantity allotted to him by his work.

In this way the prison may one day become a technical school of
moral and professional education. After all, to enclose within four
walls a creature with anti-social tendencies is not conducive to making
him more sociable. The hope is expressed that some day, not far
distant, we may see the asylum-prison on the one hand, and the prison-
school on the other, with the “ indeterminate sentence ” as a corollary.
Without losing their restraining character, the prisons of the future
ought to be, before everything, a means of prophylaxis and of criminal
therapeutics. It is more useful to treat and to cure delinquents than
to punish them ; the incurables ought to be rendered harmless, but
treated with humanity.

In the subsequent discussion Dr. Decroly emphasised the importance
of prophylaxis in the case of criminality. Prevention has taken the
first place in the fight against physical disturbances ; why should it not
be the same in the case of intellectual and emotional disturbances ?

The second paper is a critical review of the suggestions expressed in
the preceding paper. Duchateau and Masoin are far from contesting
the utility of these annexes as observation quarters for those delinquents
suspected of mental troubles, but they oppose the further uses to which
Heger-Gilbert and Vervaeck would put them: thus they consider the
establishment of a special service for the psychic treatment of abnormal
cases would involve great difficulties of organisation. Duchateau and
Masoin would prefer devoting an entire prison to these purposes, and
suggest, as a preliminary experiment, that a section of the central
prison at Ghent might be suitably transformed. It is pointed out that,

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at the present time, this particular prison with its “ common quarters”
already serves as an exutoire for large numbers of abnormal and
suspected cases. There is actually in existence at Ghent a state of
things that could be perfected before undertaking the organisation of
the other sections.

The authors consider that all these reforms should have as corollaries
the “indeterminate sentence,” with the principle of “social defence”
inscribed in the code. This being regulated by the legislature, together
with all measures of a practical order which that system involves, the
rest would naturally follow. Norman R. Phillips.

Trade Unionism and Temperament : Notes on the Psychiatric Point of
View in Industry. (Mental Hygiene, April, 1920.) Southard, E. E.

The final account of trade unionism will doubtless be given in terms
of mass psychology; but of this so little is at present known that,
in endeavouring to apply mental hygiene to industrial problems,
psychiatrists may serve themselves best by the distinctions of the
psychology of the individual. In our gropings in a subject so obscure,
Dr. Southard, whose untimely death we who now read his last public
utterance must the more lament, leads us to safe ground in the
individual psychology of the old Greek physicians—men who had
insight and hope (were “ humourists,” as we say), and, as the modern
work on glands of internal secretion seems to show, had caught the
right emphasis. He takes Hoxie’s four main functional types of
unionism and he finds that they correspond to the four classical
temperaments. His point is not to say that trade unionists of one
functional type are all temperamentally equipped in a certain way j
rather that he can show by these means that in the study of such a
problem the psychiatrist does not lack a method of his own.

(1) “Business unionism,” accepting the wage system as it is, seeks
the best obtainable terms of employment for its own membership. Its
method is collective bargaining supplemented by mutual insurance
and occasional resort to strikes. Its outlook is that of the craft or
trade; its aims are somewhat narrowly economic. Southard associates
this type with the phlegmatic temperament of relative indifference to
pleasure or pain of ordinary degrees. From such persons we may expect
business-like reactions, with not too much colour and not influenced by
temperamental extremes.

(2) “Uplift unionism” accepts, along with the wage system, the
whole existing social order. Its mission is to diffuse leisure-class
culture and bourgeois virtues among the workers. Mutual insurance
is its main function and homiletics its preoccupation. With this type
the sanguine temperament is associated.

(3) “ Revolutionary unionism ” avowedly aims at the overthrow of
the existing socio-economic order by and for the working class. There
is a parallel in the mental attitude of the revolutionary and that of the
confirmed melancholic. The latter, particularly of the more advanced
years, is apt to centre his thought upon certain ideas which in frank
cases of mental disease may amount to delusions. The revolutionary
shows his resemblance to him in the grounding of all his life upon

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definite ideas or hypotheses philosophically held, as well as in his
unpleasant emotional tone of a felt passivity, illustrating for him the
passivity in which he conceives the world around him to be, and
providing the motive of the violence he advocates.

(4) “ Predatory unionism” practises secret violence rather than
open. It is lawless, and in so far anarchistic, but it professes no far-
reaching philosophy, nor does it aim at anything beyond the immediate
economic advantage of its own membership. It is easy to see in this
type the choleric temperament. Here are men working, not on the
comparatively high intellectual plane of the revolutionary unionist, but
on lower instinctive levels. The revolutionary will have his reasons;
the predatory will act on impulse.

The modern psychiatrist may be able to add to the classical
doctrine or he may be able to overthrow the classical distinctions
altogether, but it is upon some such analytic line that, in the solution
of many a problem with which the world is confronted, he will be able
to help. It will not turn out to be a matter of the head alone, with its
scientific management, nor of the heart with its welfare programme,
nor of the long arm of the law with its ideal of social justice. In such
complicated fields as this of trade unionism, it is the individual
categories of medicine—the art which of all arts has from the beginning
taken the individual as its object—that will, as we hope, be of service
to the world. Sydney J. Cole.

The Classification of Industrial Applicants. (The Amcr. Journ. of Itts.,
April, 1920.) Stearns, A. IV.

During the past few years interest has been shown in the analysis
of the personnel of industrial houses. A decided impetus has been
given this work by the success of group tests as applied in the U.S.
Army. This paper is a discussion of the industrial problem based
upon two years’ experience of psychiatric work in the U.S. Navy.
The writer believes that some method of determining the mental
health and capacity of industrial applicants should be adopted by
every employer of labour. Two objects should be kept in view: (1)
the detection of the unfit; (2) the classification of the fit. The
interview is the only rational means of detecting the first group. The
interviewer and applicant should be alone. Information is sought for
under five headings and the interview can be completed, if necessary,
in one minute. Appearance: The expression, attitude, manner,
emotional tone, and, above all, the general type of the man should be
observed. Anything unusual must be investigated, such as shabby
clothing. This may be vagrancy or unavoidable. Geographical factor :
All misfits tend to roam, so the place of birth and the various places of
residences are of importance. Formal education : The examination
for the higher standards usually weeds out the feeble-minded congenital
cases and the very unstable. Occupation : The sort of work and the
progress made is important. A man who has held a good job for
some years is not apt to have nervous or mental disease. Defectives
and the unstable tend to change jobs frequently, and to get into
different sorts of unskilled work. General health : Many psychopaths

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and psychoneurotics are chronic invalids, complaining of vague aches
and pains, rheumatism, weakness, etc. None of the above points
prove disability, but by this examination a small group of applicants,
about io per cent., is isolated for a more thorough study. Of these
nearly half will be found unfit, and will be responsible for accidents,
thefts, etc.

The classification of the fit. —This is studied under five headings :
(i) Physical condition. (2) Mental capacity. The author uses the
following tests: (a) Traube C; {b) dissected sentences from Binet-
Simon scale; ( c ) cancellation test; ( d) memory span for numerals;
(e) Healy code ; the total marks obtainable being too. The applicants
were divided into four groups: (1) Below 65, inferior; (2) 65 to 75,
low average; (3) 75 to 85, high average; (4) 85 to 100, superior.
Practically it was found that there was a tendency for the low men to
fail and for the high to succeed, and no man was admitted to a naval
school from group 1, this comprising 30 per cent, of the personnel.
Educational classification: The applicants were put into four groups :
(1) Less than 8th grade (New England schools); (2) 8th grade; (3)
High School; (4) College. Industrial classification : Again four groups
were made: (1) Misfits or failures, as vagrants, criminals, etc.; (2)
unskilled, as students, or day labourers; (3) experienced, those not
fully trained, but who show enough ability to make this worth while;
(4) trained.

In addition to the above groupings, each occupation was given a
serial number from 1 to 53. This made it possible to give every man
a numerical formula representing his capacity and training. The
number allotted to his occupation was put at the right of a decimal
point. For instance, 111-34 would mean inferior intelligence, less
than 8th grade education and industrial failure, his work being odd
jobs. C. W. Forsyth.

5. Mental Hospital Reports, 1918-19.

Metropolitan Asylums Board .—The report for 1918 is very attenuated,
and only a brief paragraph is devoted to each of the public services which
come within the scope of the Board’s many activities. Among these
services not the least important is that which deals with the imbecile
and feeble-minded.

The range of cases, the care of which is undertaken by the Board,
comprises:

(a) Cases of imbecility and feeble-mindedness certified under the
Lunacy Acts as suitable for workhouse care, which are divided into
improvable and unimprovable.

(b) Uncertified feeble-minded.

The Board’s institutions consist of five asylums for imbeciles and two
industrial colonies for imbeciles and feeble-minded.

The care and reception of cases under the Mental Deficiency Act,
1913, was undertaken subject to the authorities concerned agreeing to
pay the full cost of maintenance, and to the Board of Control waiving
uch of their requirements as are not obligatory under the Act. As

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1920.]

MENTAL HOSPITAL REPORTS.

477

regards these cases, the unimprovable adults are accommodated at
Leavesden and Caterham and the unimprovable children at the Foun¬
tain Asylum. The trainable juveniles are sent to Darenth.

Statistics are given showing the movement of the asylums population
during 1918. The total admissions under the Lunacy Acts were 894,
and the average daily number resident 6,o86. Judging by the number
accommodated during previous years there must be nearly 2,000
vacancies.

As in the county and borough asylums, the death-rate has risen
during the war, being 27^05 per cent, on the average number resident—
more than double the average of the previous decade. Having regard
to the fact that a large proportion of the patients are congenital and
senile cases, the death-rate has not advanced as much as might have
been expected, and is indicative of a state of affairs highly creditable
to the Board and its staff. Tooting Bee Asylum must be one of the
saddest institutions in the country, with its death-rate of practically 50
per cent, of the average daily numbers.

The number of uncertified feeble-minded patients under treatment
was 777, of which 61 were admitted during the year.

Cases were dealt with under the provisions of the Mental Deficiency
Act for the first lime, and some 271 were admitted during the year, of
whom 19 were discharged and 18 died.

The cost to the Board of its asylum service was .£301,970.

St. Audty's Hospital (Suffolk District Asylum).—Dr. Whitwell draws
attention to the fact that, at this hospital, no less than 46 out of the
97 patients discharged or transferred were dealt with under Section 99
of the Lunacy Act, 1890, and sent to the care of friends. During the
past twenty years 675 patients have been discharged in like fashion, of
which only 24^3 per cent, have been readmitted.

This possibly has some relationship with the recovery-rate of i2'43 per
cent., calculated on the total admissions during the year, which is low
in comparison with 27^4 per cent., the rate for the whole of the county
and borough mental hospita s (the lowest ever recorded^ forthe same
period. It is presumed that the cases discharged to the care of friends
are included among those recorded in Table A2 as “ relieved.” Since
1 9° 2 > 3>734 patients have been admitted, of whom 655, or i7’5 per
cent., were discharged as “recovered” and 712, or 19 per cent., as
“ relieved.”

Of course it is recognised that there is no such thing as a fixed
standard of “ recovery,” and the stage at which a patient may be said
to have recovered is merely a matter of medical opinion. This no
doubt accounts in a great measure for the different recovery-rates at
various hospitals dealing with, on the whole, the same class of patients.

Quite apart from any views Dr. Whitwell may hold, a low “recovery”
rate and a high “ relieved ” rate could be accounted for by a high
standard of mental health for “recovery” being held, or a preference to
discharge patients as “ relieved ” for further convalescence to be com¬
pleted at home.

The latter procedure may have features which commend it apart
from the relief afforded to the mental hospital accommodation and the

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478

NOTES AND NEWS.

[Oct.,

lessened cost to the public, though undoubtedly the recovery-rate would
suffer thereby. It is possible that, under favourable circumstances,
final convalescence is hurried on, and of a more durable character.
Against it, is the risk of an early relapse and the trouble of re-com¬
mitment to care. The ideal would be either a prolonged period of
“ trial,” or an arrangement whereby all cases should be discharged
as “relieved,” and not recorded as “recovered” until a satisfactory
certificate of mental health is forthcoming twelve months later.
Though this is hardly practicable, yet something should be done
toward standardising the meaning of a recovery-rate, for no recovery-
rate is of the slightest value unless it can be considered with the
relapse-rate within some definite period of time.

The death-rate for 1918 (10 5 per cent.) was the lowest for the last
eleven years. For 1915, 19x6 and 1917 the death-rates were respectively
1274, ir6g and 16 62 per cent.

Dr. Whitwell remarks :

“ It is probable that these variations in the death-rate are nothing more than the
normal fluctuations which occur at all times in a population such as this; there is
not sufficient evidence upon which to associate them with any changes in diet that
have occurred during the war period, inasmuch as though the body-weight of
practically everyone in the institution (staff and patients) fell a few pounds, largely
owing to the diminution in fat-forming substances, it quickly became stabilised on
the new diet, and, moreover, the sick diet never changed in any single particular
during the whole period of the war.”

Turning to the financial report a very healthy state is revealed.
During the year the balance in hand on maintenance account of
^1,572 13s. id. rose to .£3,506 4^. of which £3,285 14J. was

cash in hands of the Treasurer. The buildings and repairs fund account
showed a balance in favour of £1,683 155. id., and likewise the farm
account of £2,734 o.r. 6 d.

Part IV.—Notes and News.

MEDICO-PSYCHOLOGICAL ASSOCIATION OF GREAT BRITAIN

AND IRELAND.

Seventy-Ninth Annuai. Meeting, held at Buxton.

The Seventy-Ninth Annual Meeting of the Association was held cn
Monday, Tuesday and Wednesday, July 26th to 28th, 1920, at the North Stafford¬
shire Mental Hospital, Cheddleton, and at the Town Hall, Buxton, under the
presidency, in the early proceedings, of Dr. Bedford Pierce, and later that of
Dr. W. F. Menzies.

EVENING SESSION.— Monday, July 26th.

Held at the Town Hall, Buxton, Dr. Bedford Pierce in the chair.

Members present: Dr. Bedford Pierce (President), Major R. Worth (Hon.
Gen. Sec.), Sir R. Armstrong-Jones, Drs. T. Stewart Adair, C. Hubert Bond,
D. Bower, A. Helen Boyle, W. Brown, J. Chambers, R. H. Cole, W. R. Dawson,
A. W. Daniel, S. Edgerley, F. H. Edwards, J. W. Geddes, W. W. Horton, J. Keay,
J. R. Lord, R. G. M. Ladell, J. Mills, A. Miller, W. F. Menzies, 1 . Middlemass,
J. McClintock, Colin F. F. McDowall, S. R. Macphaii, A. W. Neill, W. F. Nelis,
M. J. Nolan, E. S. Pasmore, G. G. Parkin, C. S. Read, G. M. Robertson, M. L

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1920.]

NOTES AND NEWS

479

Rowan, B. H. Shaw, C. J. Shaw, T. W. Smith, J. B. Spence, W. H. B. Stoddart,
E. W. D. Swift, F. R. P. Taylor, F. P. Thomas, VV. R. Thomas, W. G.
Thomson, E. W. White, W. D. Wilkins.

Visitors : Messrs. F. Dawson, E. Goodley, G. McClintock, Edward C. Myott,
W. F. S. Nichols, T. N. W. Nolan, H. T. Pebworth, E. H. Taylor, T. A.
Williams.

The following members wrote regretting their inability to be present: Sir James
Crichton-Browne, Sir F. W. Mott, Dr. Sidney Coupland and Drs. H. de M.
Alexander, G. A. Auden, G. N. Bartlett, J. S. Bolton, J. Brander, R. B. Campbell,
M. A. Collins, F. M. Cowen, M. Craig, H. Devine, J. F. Dixon, R. Eager, J. R.
Gilmore, R. D. Hotchkis, H.C. MacBryan.J. C. Mackenzie, G. D. McRae, D. Orr,
A. R. Oswald, J. G. P. Phillips, F. E. Ramsford, J. N. Sergeant, G. E. Shuttle-
worth, J. H. Skeen, P. Smith, G. W. Smith, R. H. Steen, R. C. Stewart, J. G.
Soutar, D. G. Thomson, H. Wolseley-Lewis.

Members present at the Council Meeting: Dr. Bedford Pierce (President), Major
R. Worth (Hon. Gen. Sec.), Drs. T. Stewart Adair, D. Bower, A. Helen Boyle, J.
Chambers, R. H. Cole, A. W. Daniel, W. R. Dawson, J. W. Geddes, J. Keay, J. R.
Lord, W. F. Menzies, A. Miller, M. J. Nolan.

Minutes.

The minutes of the last annual meeting were taken as read and approved.

Election of Officers of the Council.

The President proposed: That the officers of the Association for the year
1920-1 be:

President. —Dr. W. F. Menzies.

President-elect. —Dr. C. Hubert Bond.

Ex-President. —Dr. Bedford Pierce.

Treasurer. —Dr. James Chambers.

Editors of Journal. —Drs. J. R. Lord, H. Devine, G. Douglas McRae and
W. R. Dawson.

General Secretary. —Dr. R. Worth.

Registrar. —Dr. A. Miller.

This was agreed to.

He next proposed: “That the nominated members of Council be Drs. M. J.
Nolan, R. D. Hotchkis, D. G. Thomson, G. W. Smith, Sir Frederick Mott, and
Prof. G. Robertson.

This was likewise carried.

Election as Honorary Member of Dr. Colin, of Paris.

The President said it gave him much pleasure to submit to members the
proposal that Dr. Henri Colin, mddecin en chef de 1 'asile de Villejuif, Secretaire
Gdndral de la Socidtd Medico-Psychologique de Paris, Editor, Annales Medico-
Psychologiques, be elected an Honorary Member of the Association. Many would
remember the last visit of their distinguished confrere to England and the very
interesting paper which he read on that occasion. They would also have a lively
recollection of his genial personality.

The motion was unanimously agreed to. It was supported by Drs. Menzies,
Steen, Miller, Chambers, and Worth.

Appointment of Auditors.

The meeting agreed to the proposal to appoint Dr. F. H. Edwards and Dr.
C. F. F. MacDowall auditors for the current year.

Committees.

The members of the following Committees were severally re-appointed :
Parliamentary Committee.

Educational Committee, to which the names of Sir Frederick Mott and
Lieut.-Col. W. R. Dawson were added.

Library Committee.

Research Committee.

Post-graduate Study Committee.

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NOTES AND NEWS.

[Oct.,

Report of the Council.

The Secretary (Major R. Worth) read the Report of the Council for the year :
The number of members—ordinary, honorary, and corresponding—as shown in
the list of names published in the Journal of Mental Science for January, 1920, was

626, as compared with 626 in 1919.

Number of new members elected in 1919 . . . .21

Number of members restored in 1919 ..... o

Removed according to Bye-law 17.o

Number of members resigned in 1919.12

Number of deaths in 1919 ....... 9

Transferred to Hon. Members ...... o

The following table shows the membership for the past decade

Members.

1910.

1911.

1912.

1913-

» 9 M.

I 9 I<.

1916.

19*7.

1918.

■ 919.

Ordinary

680

690

696

695

<579

644

632

627

626

Honorary

33 ,

26 ;

Corresponding

1 7

Total

730

743

750

747

73 <

696

682

678

676

661

We have to report that Lieut.-Col. Keay has been appointed Chairman of the
Education Committee, and Dr. Collins Vice-chairman, Dr. Maurice Craig having
asked to be relieved of his duties after having served for many years.

Lieut.-Col. W. R. Dawson was elected to fill the vacancy caused by the lamented
death of Dr. T. Drapes, and Dr. H. Devine and Dr. G. Douglas McRae were also
elected to complete the Editorial Staff of the Journal.

Dr. Bedford Pierce was elected to serve on the Council of the Nurses Regis¬
tration Bill, and it was proposed that the Medico-Psychological Association should
join the British Federation of Medical and Allied Societies, and that Dr. R. H.
Cole should be the representative. That an entrance fee of £2 2s. and annual
subscription of £7 7 s. be paid.

A deputation of the Medico-Psychological Association was appointed to inter¬
view the Minister of Health, at which many points affecting the Association were
discussed with satisfaction.

Following a meeting at the Guildhall regarding the training of nurses and
probationers, Drs. D. G. Thomson and A. Miller were named representatives of
the Association to confer with the representatives of the National Council of
Institutions for the Treatment and Care of the Mentally Afflicted in connection with
the formulating of a scheme for the future certification of permanent members of
the nursing staff in mental hospitals on similar lines to those on which certificates
of training are granted in general hospitals.

The Education Committee have decided, at the suggestion of the Council,
that there should be a new edition of the hand-book and that the whole syllabus
for the examination of nurses should be revised.

Drs. Thomson and Worth were appointed to confer with the N.A.W.U.
with regard to the revision of the Asylums Officers’ Superannuation Act. The
Association has communicated with the different authorities to see whether the
pensions of retired mental hospital servants could be increased.

It has been agreed that the Association should administer the Convalescent
Fund of the Asylum Workers’ Association.

Sir James Crichton-Browne delivered the first Maudsley Lecture at the Royal
Society of Medicine on May 20th.

At the May meeting it was agreed that Dr. C. Hubert Bond should be nominated
President-Elect.

A special Sub-Committee has been formed to go into the matter of post¬
graduate study.

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1920.] NOTES AND NEWS. 481

We greatly regret having to announce the deaths of Drs. T. Drapes, C. A.
Mercier, E. G. Fearnsides, and E. S. H. Gill during the past year.

The report was received and approved.

Treasurer’s Report.

The Treasurer (Dr. Chambers) submitted the revenue account and balance sheet
for 1919. He pointed out that there had been a considerable diminution in the
cost of the production of the Journal, and thanks were due to the Editors for
having carefully regulated their requirements in accordance with the increased cost
of labour and materials, and the falling revenue. Owing to the Editors’ wise
economy, and to the amount of arrears which had been paid, the balance at the
bank justified an increase in the size of the Journal for the current year; the result
will be a serious increase in the printer’s bill at the end of the year. It was very
important that the Journal should be restored to its former standard of excellence,
and, as members were aware, it was for this reason proposed to increase the annual
subscription.

Nearly all the subscriptions written off were accounted for by the Association
having excused members for the period of their foreign service. As the result of
further inquiries and correspondence, a considerable amount will have to be
written off at the end of the current year.

The Association and the General Secretary were to be congratulated on the large
number of new members recently elected.

The report was received and adopted.

Report of the Editors —1919.

During the war the Editorship of the Journal was largely in the hands of the
late Dr. Thomas Drapes, who was ably supported by Dr. Henry Devine and
Dr. G. Douglas McRae as Assistant Editors. The other Co-Editor, Lt.-Col.
J. R. Lord, was only referred to on matters of great moment or difficulty. The
death of Dr. Drapes on October 5th, 1919, was a great loss to the Association,
and especially to the Journal. Fortunately, Lieut.-Col. J. R. Lord was able to resume
active work as Co-Editor, and there was not the slightest hitch in the production
of the Journal, owing to the business-like methods adopted by Dr. Drapes, and
the admirable order in which he left it.

It thus became necessary to supplement the Editorial staff, and at the Quarterly
Meeting of the Association held on November 25th, 1919, it was decided to revert
to the custom of having four Co-Editors. Lieut.-Col. W. R. Dawson, O.B.E., as
representing the sister isle, was asked to join, and subject to their consent it was
decided that the two Assistant Editors, Drs. Devine and McRae, should be raised
to the status of Co-Editors. All this in due course materalised and the names
of the four Co-Editors appeared on the cover of the January number of the
Journal, 1920.

During 1919 the Journal began to recover from the embarrassments imposed by
war conditions, and its size remained curtailed for financial reasons only. In the
April number, 1919 (p. 65), was a notable contribution by the late Dr. Henry
Maudsley on " War Psychology: English and German,” one of his last pro¬
ductions—the importance of which will, no doubt, be more and more appreciated
when the future history of Europe comes to be written.

The Journal took a new lease of life in January, 1920, and the Co-Editors are
grateful for the very satisfactory support accorded them by the members of the
Association. More assistance, however, would be thankfully received as regards
Reviews and the Epitome. With an improvement in the financial position of the
Association it will be possible to expand the Journal to its former size, and to
enhance its importance and interest by the publication of more illustrations, which
have to be restricted in number at present. For the Co-Editors.

John R. Lord.

Lt.-Col. Lord moved the adoption of the report.

The President congratulated Col. Lord on the excellent standard maintained
by the Journal, and the great pains he had taken to bring it back to its pre-war
standard.

Lieut.-Col. Lord, in acknowledging the President’s remarks, made sympathetic

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PRINCETON UNIVERSITY

1920.]

NOTES AND NEWS.

483

reference to the late Dr. Drapes and his work as Editor. He said he found, after
having been out of touch with Journal matters during the war, that everything
connected with it was in such excellent order that there was no difficulty in resum¬
ing office.

The report was duly adopted.

Report of the Sub-Committee on Post-Graduate Study.

Lieut.-Col. J. R. Lord communicated a verbal report on the work of this Sub-
Committee. He said that, following the direction of the Association, he convened
a meeting of this Sub-Committee on June 30th, 1920, at No. n, Chandos Street,
London. There was a good attendance of members, and Dr. Hubert Bond was
elected Chairman, and himself (Col. Lord) Secretary. Acting on the powers given
to the Sub-Committee in the reference, they added thereto Prof. G. Robertson
(Scotland), Dr. J. O’Conor Donelan (Ireland), Dr. H. Devine, Dr. J. Middlemass,
and Dr. E. Goodall (Wales). The second meeting had been held that day
(July 26th), when the matter was further discussed. It was found to be a very
intricate one, but some further progress was made. The next meeting would
probably, he said, be called in September.

Report of the Parliamentary Committee.

Dr. R. H. Cole read this report :

The Committee has met four times as in previous years. The Committee has
continued to urge the claims of mental nurses and is able to report that it has
secured for them fair representation in the Nurses Registration Act, also that Dr.
Bedford Pierce has been appointed on the first Council established by that Act,
and further that the Minister of Health has been approached with the view to the
formation of a supplementary register for nurses trained in institutions for mental
defectives. Suggested amendments to the Asylums Officers’ Superannuation Act,
1909, have been considered and a conference has been held between representatives
of this Association and the Clerks' and Stewards' Association and the National
Asylum Workers' Union with the object of preparing an amending Bill. Efforts
have been made to promote legislation to improve facilities for the early treat¬
ment of mental disease on the lines laid down by the recent Report of the
Association, and a deputation was received very sympathetically by the Minister
of Health on this subject. The same matter is being pressed forward by the
newly formed British Federation of Medical and Allied Societies which the
Association has joined.

H. Wolseley Lewis, Chairman,

R. H. Cole, Secretary.

It was duly agreed to.

Report of the Auditors.

Dr. F. H. Edwards submitted this report:
We have examined the vouchers and books
report that the balance sheet and revenue
financial position of the Association.

The report was agreed to.

of the Association and beg to
account present accurately the

F. H. Edwards

G. F. Barham

| Auditors.

MORNING SESSION.— Tuesday, July 27TH.

Held at Cheddleton Mental Hospital, Dr. Bedford Pierce in the chair.

Report of the Educational Committee.

Dr. A. W. Daniel moved the adoption of the following report :

This Committee has held eight meetings, and in addition much work has been
done by Sub-Committees.

One candidate presented himself for the Professional Certificate Examination,
and he was successful.

There was no candidate for the Gaskell Prize and Medal.

LX VI. 3 2

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484

NOTES AND NEWS.

[Oct.,

The number of candidates for the Nursing Certificate is showing a great
increase now that the training of mental nurses is compulsory. The numbers
last May were for the Preliminary 2036, of whom 1308 were successful; for the
Final 612, of whom 371 were successful.

A Sub-Committee has been formed to arrange for the rewriting of the Hand¬
book for Attendants on the Insane, and their work is in progress.

Much time has been spent on the revision of the syllabus of training, the
regulations, the schedules, and the rules for the conduct of the examinations.
Our suggestions have been approved by the Council and are now presented for
confirmation. It may be stated that the more important alterations are:

(1) That the three years of training must be spent in one institution or
service, as decided at the last annual meeting.

(2) That instead of two examinations there shall be three, one at the end of
each of the three years of training.

(3) The minimum number of lectures and demonstrations has been materially
increased.

(4) The regulations are to apply to all nurses joining the service after
November, 1920.

Regulation No. 5 reads as follows :

(5) Nurses who possess certificates of having trained for three years in a
general hospital, or poor-law infirmary, approved by the Council, sha:l
be exempt from the First and Second Examinations and shall be eligible
for the Third Examination for the Medico-Psychological Certificate after
training for a further period of one year in one recognised institution.

(6) The fees payable by candidates have been increased.

(7) It has been decided that examiners and coadjutors shall be paid.

The proofs of the regulations and syllabus will be obtainable from the General
Secretary.

Lieut.-Col. J. Keay seconded.

Prof. George Robertson (Edinburgh) said there was one item in the Report
to which he would like to direct attention. He referred to that part in
which it was stated that a nurse who had received training at a general
hospital might leceive the nursing certificate of the Medico-Psychological
Association after only one year's further training in a mental hospital.
That constituted a departure from past observance, when two years’ further
training in a mental hospital was the time insisted on. On that point he
did not think anyone would accuse of him of not taking an interest in hospital
nurses. He had often spoken on their behalf; probably, in the opinion of many,
much too often, for he had done it in season and out of season. Hence he could
claim to have shown himself to be thoroughly interested in their welfare. But
he regarded the present intended alteration in the Association's regulations in this
respect as a very serious departure, and one which ought not to be accepted by
members. He therefore wished to move that the Report be referred back to the
Committee for re-consideration and further report. The first hospital nurse
introduced by him, who worked in the general wards of an asylum, was at
Murthly Asylum, in Perthshire, in 1896. Nurses had previously been trained
in asylums by Dr. Campbell Clarke, and he recently met one of the first of these
nu rses, who presented to him the certificate which she had obtained from Dr.
Campbell Clarke—the first obtained by a mental nurse. After that the Scottish
Division of the Association took up the training, and, at a later date still, the
Association as a whole took it up. In furtherance of the idea of employing
hospital-trained nurses in mental work he proposed in this Association twenty
years ago that, seeing that the training of hospital and of mental nurses overlapped
considerably with regard to such subjects as physiology, anatomy, and general
nursing in emergency, hospital nurses might be relieved of one year of training, and
be granted a certificate after two years’, instead of three years’, training. At
that date so little did the Association approve of a reduction in the length of the
training that not one member was found to support his motion, and he was unable
to find a seconder. Not until ten years later was the reduction made from three
years to two for hospital-trained nurses; and on that occasion it was proposed by
Dr. Mercier, and was carried without dissent. He, the speaker, approved of the
time of the training beirg reduced, but he was strongly against the proposed

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further curtailment to one year, and that for a variety of reasons. He had
probably trained more hospital nurses in mental work than had anybody else.
He did not think the average hospital nurse understood in one year mental cases
nor acquired the proper attitude concerning them. These hospital nurses came
to asylums looking at disease from a physical, not from a mental standpoint.
To show how different was the attitude of the hospital nurse from that of the
mental nurse, when the latter sat down by the bedside of a patient to understand
the patient, the hospital-trained sister would ask her if she had nothing to do.
In asylums it was well understood that one of the main duties of a nurse was to
sit down by the side of patients, talk to them, and try to elucidate and understand
their personality. The general hospital nurse received a training in technique
and in method, whereas the mental nurse required to be trained in resourcefulness
and observation. The training in the two cases was of a different kind. There¬
fore not only did hospital nurses require to overcome some handicap when they
came to an asylum, but even general practitioners, of whom he had had some
experience during the war, when they came into an asylum did not seem to get
into touch with the patients, or ever to understand mental cases. Dr. Yellowlees,
the present “ Father ” of the Association, Dr. Clouston, and Dr. Rutherford all
stated it was preposterous to think hospital nurses could ever look after mental
patients. That was wrong, but he was sure they would be opposed to reducing
the period of training of hospital nurses in asylums by another year.

The other objection he felt to the change was, that he thought they would be
degrading the value of the mental certificate by saying that for such nurses one
year of asylum training was sufficient to learn all that was required in order to be
able to look after mental cases. (Hear, hear.) A great deal of trouble had been
experienced in getting the public to appreciate the good work which mental nurses
did, and how they kept up to the demands which were made upon them. There
had always been a tendency for hospital nurses to look down upon mental nurses,
for that department of the profession had been regarded as the Cinderella of
nursing. It had, however, a fairy godmother in the Association, and through
it mental nursing had attained to a status and position which had become higher
and higher, and had it not been for the regrettable threats of strikes, the outcome
of general industrial unrest, during the last year or two, they might have now been
almost on a level, in the estimation of the public, with hospital nurses. But if now
the Association were to step in and state that hospital nurses who had scarcely
been in contact with mental patients could learn all that they required to learn in
one year, it meant a depreciation of the value of the training in this special
branch of nursing.

The other point in connection with this matter was, that the General Council of
Nursing would have to consider all the statutory regulations regarding training.
If this Association were now to pass the suggested alteration to the effect that one
year’s mental training for the hospital nurse was sufficient, it was possible that the
General Nursing Council might order that the hospital nurse should have two
years of training in a special hospital before she could be regarded as being an
efficient mental nurse. Therefore they were, to some extent, in the hands of the
Nursing Council. Of course the latter would take advice from this Association,
but he thought it would be disadvantageous for this meeting to depreciate the
value of asylum training. It was hoped that reciprocity would be achieved
between the different branches of nursing. For many years past hospital nurses
had been relieved of one year of training because of this overlapping, but a similar
favour had not yet been granted for mental nurses passing to general hospitals,
though he understood that was being contemplated. When the College of
Nursing was being established, he put that point to Sir Arthur Stanley, and that
gentleman agreed that arrangements should be made to grant a similar concession
to mental nurses to that which had been conceded to hospital nurses. But if this
Association was going to pass a regulation of the kind set forth in this Report,
degrading the value of the period of mental training, it was not at all likely they
would be able to get concessions on equal terms.

For those reasons he sincerely trusted—and that because he was interested in
hospital nurses in asylums—that this proposed alteration would not be approved,
but that the Educational Committee would reconsider this serious departure.

The President said, as a matter of procedure he understood Prof. Robertson's

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proposal to be that this Report be referred back. He was not sure, however, that
that would not be rather unfortunate. It would place the Educational Committee
in rather a difficult position in regard to their new regulations. He understood
Prof. Robertson’s criticism was directed to only one item in the Report. On
looking at the Association’s rules, it appeared that the Educational Committee was
entrusted with the regulation of the examinations for the Certificates of the
Association, and such other matters touching the teaching of psychiatry and the
nursing of the insane as are designated to it by the Association or by the Council.
It did not say it was entrusted with the carrying out of the regulations. Still,
however that might be, if the annual meeting did not approve of the Report of the
Educational Committee, it would be difficult for that Committee to go on. He
was wondering whether Prof. Robertson would be satisfied to agree with the
adoption of the Report, with an express amendment on the point he had criticised.

Prof. Robertson said he preferred to take that course; that the Report as a
whole be adopted, with the amendment that instead of the word “ one," the word
“ two ” be inserted. He did not put his remarks in the form of a motion, as he
did not think that would be in order.

Dr. S. R. McPhajl seconded the motion with pleasure. Prof. Robertson's
speech was the most interesting one he had ever heard that gentleman make. He
would simply be a Saul among the Prophets and second it.

The President said the matter was now before the meeting. They must take
this one question now only, afterwards going back to the remainder of the Report.
This particular amendment referred to whether nurses who were trained in general
hospitals or poor-law infirmaries should be exempted from the first and second
examinations.

Lieut.-Col. E. W. White said he wished strongly to support Prof. Robertson on
this matter. It was quite true to say that the training of nurses originated in
Scotland. It was in the ’8o’s—about 1887—that it was introduced into England,
namely, in the City of London Asylum. Dr. Greenlees, a Scotsman who was the
speaker’s active coadjutor in the matter, and he both favoured the project. They
trained a large number of nurses, and for the first three or four years they issued their
own nursing certificate from the City of London Asylum. When the Association
started issuing certificates, the City of London Asylum cancelled theirs in favour
of the Association’s. Many nurses passed through that asylum, and then went
into general nursing, for which they had to do three years' training. One or two
general hospital nurses came to the asylum and obtained the nursing certificate of
the Association. He considered it absolutely essential, for the maintenance of the
real value of the Association’s nursing certificate, that the two years in an asylum
should be exacted, as proposed by Prof. Robertson, in place of one year as set out
in the Report. The latter would mean a depreciation, a lowering of the standard
of the certificate, which required to be kept up to the highest point. He regarded
the matter as one of very great importance, and asked his hearers, in coming to a
decision, to consider the future, and insist on the certificate being valued as it
should be.

Dr. W. F. Menzies said this Report came from the Educational Committee
on the recommendation of a special Sub-Committee. He was not himself a
member of that Sub-Committee, and therefore he was able to speak independ¬
ently. They mentioned that the foundation of their request for an alteration
from two years to one year was, that for two years the training was in ordinary
nursing subjects, and during the third year there was specialisation in mental
subjects. That, of course, constituted a strong argument. The other reason was,
in his mind, that to object to one year was not the way to go about it. He could
cite six cases he had had in the last year who were willing to come for one year,
but were not willing to come for two years. Members of the Association must
not confine themselves to their own training, but must consider also midwifery
and other accessory departments. For many years he had heard, at intervals,
that Prof. Robertson and his coadjutors were the earliest to introduce hospital
nursing in asylums ; he now expressed the hope, once for all, that Prof. Robertson
would not repeat that statement. If that gentleman could only cite 1896, he, the
speaker, could tell him that more than four years earlier Dr. Wiglesworth had
hospital-trained nurses in the wards of Rainhill; when he, Dr. Menzies, was there
in 1891 they were there. Hence it was not Scotland which began this thing, it was

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England. His experience of those nurses, from 1890 onwards, was that only the
enthusiast came to the asylum, that the nurse qualified by hospital training who
wanted to learn the nursing of mental cases was a girl who was interested in her
profession, and took good care that in a year she would become efficient in
mental nursing, and would understand all the principles of it. The ordinary
hospital nurse was so bad that everyone was quite willing to part with her in six
months. The good nurse who was interested in her work could be easily trained
in one year if she had secured a good hospital certificate beforehand.

Dr. E. S. Pasmore desired to support Prof. Robertson's amendment in favour
of two years of mental training for hospital nurses as a condition of securing the
Association’s nursing certificate. He thought Prof. Robertson struck the key-note
when he said the reduction of the two years of mental training to one year
would depreciate the value of asylum training. Prof. Robertson’s description of
the attitude of the hospital nurse in the asylum was true—she did not appreciate
the importance of mental disease. All her training for two or three years had
been concentrated in the wards, and if one spoke of patients committing suicide,
these nurses, in the first few months, showed a tendency to laugh at the idea. He
remembered having on the staff of his asylum a lady who had been assistant-
matron at a general hospital. She was like a baby in the asylum, and for the
first nine months did not seem able to do anything helpful. She appeared to be
continually under the impression that anything in an asylum was derogatory, and
not up to the standard of hospital nursing. He believed that if the training of
hospital nurses in mental work were reduced to one year, the status of mental
nurses would be depreciated. They would be even more looked down upon by
hospital-trained nurses, and he did not think any larger number of nurses would
be attracted to asylum work thereby.

Dr. R. H. Cole said the subject now being discussed was a very important one.
Medical officers engaged in dealing with mental disease had been apart from physical
disease practitioners so long that they should now try to come together. This was
an opportunity to do so by means of the nurses. Everybody would acknowledge
that the nurse in the general hospitals would not come to the asylums as the
regulations existed at present. They were willing to enter asylum service as
“ superior persons,” via., as assistant-matrons, but not as nurses, thereby,
as Prof. Robertson had said, depreciating the true value of mental nursing. Hospital
nurses were being taught about mental disorders, and that people undergoing
treatment in hospitals were not to be regarded as persons suffering from physical
diseases only, but also as personalities. Lectures were now being given to nurses at
general hospitals on mental disorders. He considered that mental nursing was a
branch of general nursing and to some extent subsidiary, as also were midwifery and
other branches. He thought there ought to be reciprocity ; that a woman should
be required to train in a mental hospital for only one year if she were a hospital
nurse, and that mental nurses should only be required to train in a general hospital
two years to be physical nurses. He felt very strongly about this. He was on
the Sub-Committee, the members of which thought it desirable to make this
change. He was, therefore, against the amendment.

The President said it would be well to have a considerable expression of
opinion, if only briefly, from each member, before it was put to the vote, as the
matter was an important one.

Dr. M. J. Nolan said he had had hospital nurses in his hospital since 1894, and
therefore he knew something about it. He wished to say a word in favour of
one year’s training in a mental hospital. He considered that a hospital nurse,
who had been well trained in a general hospital and certificated, if she were worth
anything, would be able to pick up what was required to make her efficient in
mental nursing in one year. He looked upon it as a similar case to that of the man
who had a licence in surgery and medicine yet took a midwifery diploma in addition.
One would not expect a man to possess a diploma in midwifery before he was
qualified in medicine and surgery. Similarly, he thought a hospital nurse who
had put in three years of general training should be able, after one year's training
in an asylum, to learn ample for the purpose. And this would have the effect of
bringing into asylum service a large number of nurses who were anxious to come
in order to gain knowledge of mental nursing, but who might not come if the
period required were to be made more than one year.

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Dr. J. Mills desired to utter a brief word in favour of the one-year period. He
did so because the admitting to the asylum service of nurses who already possessed
a knowledge of physiology, anatomy and general nursing would be an advantage
generally in the treatment of the patients. He favoured the one-year regulation
with the view of improving the general standard of the staffs of asylums, on the
principle that “ a little leaven leaveneth the whole."

Dr. C. J. Shaw said that for the very reasons given by the last speaker he
wished to support Prof. Robertson’s amendment. The aim should be to raise the
status of the mental nursing profession, and he did not think this would be done by
lowering the value of the nursing certificate issued by the Association. Mental
nursing was very different from ordinary physical nursing. The very best nurses
were needed in asylums, and medical officers wished to do their duty by them and
make the certificate granted to them one of real value, a value as near as possible
to that of the ordinary certificate for physical nursing. At present there was no
such reciprocity existing. If a mental nurse entered a general hospital she had to
go through the whole general training, and if general nurses were allowed into
asylums for one year and then granted a certificate, he did not think those
responsible would be doing their duty by the mental nurse. He had had con¬
siderable experience of trained nurses in asylums, and, as far as he had seen, they
were not anxious to stay there two years and take the certificate. The regulation
as it at present stood was calculated to maintain the high value of the certificate;
and asylums should have good mental nurses and the very best of the hospital-
trained nurses. If members were going to make the mental nursing certificate too
easily obtained, then it would incline ordinary nurses to view the certificate granted
by’ this Association with even more contempt than at present. Many of them
came to be assistant-matrons, and he thought the best of the asylum nurses who
obtained the Association's certificate went into general hospitals with that view,
and the best of nurses from general hospitals entered asylums with the same
object. He did not think it was advisable to reduce the value of the Association's
certificate by making the period of training in a mental hospital only one year
instead of two.

Dr. Colin McDovvall said all the speakers, so far, had been superintendents of
large institutions, where large numbers of patients had to be treated. He thought
that the views of the men who ran the smaller institutions should also be known
by the Association. In such a place as his own, where there were only eighty
patients, forty of them female, and perhaps 70 per cent, of them suffering from
chronic mental disorders, it would be seen to be impossible to think of training
women efficiently in mental nursing in the course of one year. Indeed it could not
fully be done in two years ; he doubted if it were possible in three years. He
therefore felt that the amendment now before the meeting should be supported,
making the training, at the very least, two years for general nursing in asylums.

Lieut.-Col. J. Keay said that though he moved the adoption of the Report of the
Educational Committee he hoped it would not be out of order for him to support
Prof. Robertson. He thought the Association would be making a mistake in
doing anything to lessen the standard of its certificate in mental nursing. He
thought a reduction of the time required in a mental hospital for a trained hospital
nurse would have that tendency. During the last five and a-half years he had had
considerable experience of trained nurses. He had at the present time, in the
hospital of which he had charge, a large number of trained nurses and sisters, as
well as some mental nurses. He had formed the opinion, after carefully thinking
out the subject, that a good mental nurse was better than any hospital nurse. He
believed that the best nurses in his hospital, whether for mental or any other cases,
were mental nurses. He considered that the mental nurse who had had the
Association’s training should be able to go into a general hospital and obtain the
certificate for general nursing as easily as the trained hospital nurse could enter an
asylum and obtain this Association’s certificate. He placed them, in his mind, on
an absolute equality. If that were done generally he thought they would be on
the right lines. He would not do anything to assist general hospital nurses
obtaining the Association’s certificate at a cheaper rate, or give facilities which the
mental nurse did not enjoy when she sought the general nursing certificate.

The President said he would now put the amendment to the meeting, and he
hoped that in arriving at a decision one aspect of the subject would be ignored,

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namely, the immediate welfare of the institutions. He did not think that was
germane to the subject. Because it might be convenient to get hospital nurses
into asylums on easy terms, he hoped that would not be allowed to influence
members’ decisions. He thought all members saw that the real thing was the
dignity of the mental nurse, and what was going to be best for mental nurses ; not
what was best for institutions. It would be seen that those two were not the same
thing. Members were acting as the trustees of mental nursing.

Twenty voted in favour of the amendment, ten against.

The President said that, the amendment having been carried, the proper
course was to put to the meeting for adoption the Report of the Educational
Committee as amended.

Prof. G. Robertson said it gave him great pleasure to move the adoption of the
Report of the Educational Committee as amended, and to include in it a
resolution of thanks to the Committee for their labours in the matter.

Dr. E. S. Pasmore seconded.

The President said this proposition having been duly moved and seconded, it
gave members an opportunity of raising any other matter in the Report if they
desired to do so.

The amended Report was agreed to.

Suggested Increase of Subscription.

Dr. J. Chambers proposed that the annual subscription be, in future, one-and-a-half
guineas. He explained that the increase in the expenditure was due mainly to the
cost of producing the Journal. Hitherto, since the commencement of the war, the
Association had been able to carry on owing to the Editors having reduced the
size of the Journal. But that procedure had its limitations, and it would prove
detrimental to the interests of the Association if its Journal could not now be
restored to something like its former standard of excellence. He felt it was a real
necessity that the subscription should be increased in order that the work of the
Association should be carried on properly.

Dr. J. Mills seconded, and the resolution was carried.

Travelling Expenses of the Handbook Committee.

Dr. J. Chambers, at the request of the President, proposed that the travelling
expenses of the members of the Handbook Committee be paid. He said that
this matter had received a great deal of consideration, and he hoped that the
Association would adopt this course.

Lieut.-Col. E. W. White asked whether a profit would be made out of the sale
of the handbook.

The President replied in the affirmative.

Dr. J. Chambers said the sales of the handbook had increased very much, and
last year the receipts therefrom were £60 15s. 8 d .

Lieut.-Col. E. W. White said he had much pleasure in seconding the proposition.

The President said he was a member of the Handbook Committee, and he
did not propose that the expenses other than travelling expenses of the Committee
should be paid. The Committee did not hold a large number of meetings, but
when they had occurred, members had travelled to them from Ireland and the
North of Scotland, as well as from London, Manchester, Liverpool, etc., and,
nowadays, travelling was a very expensive matter. And, seeing that this book
formed a source of income for the Association, it was regarded as not unreason¬
able that the actual travelling expenses should be defrayed by the Association.
That was the reason the matter had been brought forward.

Dr. J. Mills, in supporting the motion, said he thought the members of the
Committee should receive a guinea a night when absent from home.

Dr. J. Chambers said he could not accept that addition to his proposal.

Dr. J. Mills said that in that case he would not press it.

Dr. J. B. Spence thought members as a whole were about to commit them¬
selves to something they knew nothing about; they had no idea what the expenses
would be. The next proposition on the agenda was that the coadjutors of the
oral nursing examination should be paid. If that were adopted, it would
constitute a heavy claim on the nursing certificate profits.

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Lieut.-Col. E. W. White said it must be remembered that the Handbook Com¬
mittee was only a temporary one, which would cease to exist when the handbook
had been completed.

The President said that there was not, as yet, any amendment before the meeting,
but it was open for further discussion. He thought it would be open for the
resolution to read “ Third-class travelling expenses.” He did not think any
member of the Committee was asking for first-class travelling expenses.

Dr. J. Chambers included that in his proposition.

Lieut.-Col. E. W. White seconded the addition.

Dr. W. F. Menzies desired, as a member of the Committee, to explain that
there were certain members in Ireland and the North of Scotland who could not
afford to come to London for the meetings, and it came to be a question of either
paying the travelling expenses of such members or their being absent from the
meetings. In the latter event the Association suffered, because it was without
the experience and advice of those members. The greater part of the expenses
were hotel bills, and that the members did not expect or ask to have back.

The resolution was carried.

Payment of Coadjutors of the Oral Nursing Examination.

Dr. A. W. Daniel moved that the coadjutors of the Oral Nursing Examination
be paid one guinea for 30 candidates, or under 30 ; and over 30, two guineas ; to
include all three examinations ; and that the examiners appointed to examine the
three papers for the nursing certificates should receive ^40 per annum in
each case.

Lieut.-Col. J. R. Lord seconded.

The President said this was a new method of paying the examiners.
Examiners for the written examination sometimes received a considerably higher
fee—when there were many candidates the fees amounted to as much as £70. It
was now suggested that the examiners of the written paper should receive a ^40
fixed fee per annum. From the money so saved it would be possible to pay the
coadjutors something to meet their travelling expenses. It was understood that
the candidates for the two examinations, the first and the final, should be taken
at the same time; there were no coadjutors needed for the second examination.

Dr. S. R. McPhail said he did not quite understand the position in this matter.
Was it the idea that the Association should pay the coadjutors because it provided
them ? In the past, each superintendent chose his own coadjutor, because,
apparently, the President had never declined the nomination of the examining
superintendent.

The President replied that there was no alteration in the method of appointing
coadjutors. All appointments were subject to the approval of the President.

Dr. S. R. McPhail thought he had in his time examined as coadjutor at fifteen
different institutions, and in all except two his out-of-pocket expenses were
paid by the particular asylum. Was it not the usual practice for the asylums to
pay the coadjutors ? He thought it was right and proper for the institution to
pay these expenses. He had never asked a man to help him examine without
refunding him his out-of-pocket expenses.

Lieut.-Col. E. W. White said he could support what Dr. McPhail said. For
many years he had examined at Southern County Asylums—Darenth and neigh¬
bouring asylums—and in every instance his travelling expenses had been paid by
the committee of the institution. He thought the practice still continued.

Dr. E. S. Pasmore said he did not think, in view of the increase in remuneration
of nurses, that asylum committees would agree in future to pay as they did before.

Dr. J. Middlemass opposed the resolution. It was not the Association which
benefited by the examination, but the nurse and the institution to which she
belonged. He regarded the proposal as reasonable. He did not think any com¬
mittee would decline to pay the expenses of a coadjutor if it were put to them.
At his institution there was a St. John Ambulance examination, and they were
willing to pay four guineas expenses, and he thought the reason inducing the
institution to do it in that case would apply in this.

Dr. F. R. P. Taylor asked whether it was not true that the Educational Com¬
mittee, when they met yesterday and fixed the fees for the nursing examination.

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took into account the likelihood that they would have to provide this money for
the coadjutors. Therefore if the present proposition were negatived he took it
that the question of fees would have to come up for a further discussion.

Dr. D. Bower thought the motion should be divided into two parts : the remarks
just heard were not a mere negative. One portion related to the examiner for the
written examination, the other to coadjutors for the oral.

The President said that even if travelling expenses were paid it did not say it
was for travelling expenses: it was really an honorarium of a guinea. The coad¬
jutor could have his travelling expenses as well. The amount ottered for examining
thirty was almost an insult. (Hear, hear.)

The motion was approved.

The President said he presumed the payment should begin at the next
examination.

Motion Involving the Expenditure of Funds.

The President said he had to bring up another matter, which was somewhat
new in character, a motion involving the expenditure of funds. As Chairman of
the Handbook Committee he had had to move in the matter without the authority
of the Association as a whole. It was provided that no motion involving the
expenditure of funds exceeding ,£25 could be approved or arrived at except at
an annual meeting. He had received no authority from the previous annual
meeting to offer an eminent writer a fee of 25 guineas for writing a special chapter
for the handbook on 11 The Mind in Health." The Handbook Committee thought
it advisable to get a psychologist to write this article, who probably had now
writtei) the article. He, the speaker, now asked this meeting to sanction the fee,
and he asked a member to propose that the fee be paid, if the article should prove
to be acceptable.

Dr. F. R. P. Taylor said he had pleasure in moving accordingly.

Dr. J. Mills seconded.

The motion was duly approved.

The meeting then had a desultory discussion on the next Maudsley Lecture,
which will be definitely brought up for consideration at the next meeting of the
Association.

Dates of the Quarterly and Divisional Meetings.

The following dates for the Quarterly Meetings were agreed upon: Thursday,
November 25th, 1920; Thursday, February 25th, 1921 ; Thursday, May 26th, 1921.

The Divisional Meetings were proposed as follows :

South-Eastern Division. —October-14th, 1920, at Three Counties Asylum,
Arlesey, Beds.

Northern and Midland Division. —October 21st, 1920, at the Coppice, Notting¬
ham ; April 21st, 1921, at Gateshead Mental Hospital, Stannington.

South-Western Division. —October 29th, 1920 ; April 24th, 1921.

Scottish Division. —November 19th, 1920 ; March 18th, 1921.

Irish Division. —November 4th, 1920, at Royal College of Physicians, Dublin;
April 7th, 1921 ; July 7th, 1921.

Election of Candidates as Ordinary Members.

The following lady and gentlemen were elected as Ordinary Members:

Wanklyn, William McConnell, B.A.Cantab., M.R.C.S.Eng., L.R.C.P.Lond.,
D.P.H., Principal Assistant in the Public Health Department of the London
County Council, Public Health Department, 2, Savoy Hill, W.C. 2.
Proposed by Drs. C. H. Bond, P. T. Hughes, and M. A. Collins.

Duncan, Jessie Galloway, M.B., Ch.B.Glasg., D.P.H.Camb., Assistant
M.O.H., L.C.C., Visiting M.O., South Side Home, Streatham ; 33, Heybridge
Avenue, Streatham, London, S.W. 16.

Proposed by Drs. G. E. Shuttleworth, G. Warwick Smith, and R. Worth.

Harper, R. Sydney, M.R.C.S.Eng., L.R.C.P.Lond., F.R.M.S., Capt. R.A.M.C.,
Approved Neurologist, Ministry of Pensions, Neurologist in Charge Psycho-
Therapeutic Clinic, Ministry of Pensions, Brighton ; 4, Adelaide Crescent,
Hove, Sussex.

Proposed by Drs. H. E. Haynes, R. Whittington, and R. Worth.

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Roscrovv, Cecil Beaumont, L.R.C.P.&I.Edin., Medical Superintendent,
City Mental Hospital, Winson Green, Birmingham.

Proposed by Drs. J. B. Spence, A. Miller, and Wm. Reid.

Sutcliffe, John, M.R.C.S.Eng., L.R.C.P.Edin., Medical Superintendent,
Cheadle Royal, Cheadle, Cheshire.

Proposed by Drs. Scowcroft, Dove Cormac, and G. G. Parkin.

Clark, R. M., M.B.&C.M.Edin., Medical Superintendent, Whittingham
Asylum, Lancashire.

Proposed by Drs. R. M. Stewart, B. H. Shaw, and W. Starkey.

Henderson, Cyril John, M.B.Durh., A.M.O., The Royal Albert Institution
for the Feeble-minded, Lancaster.

Proposed by Drs. W. H. Coupland, D. M. Cassidy, and David Blair.

Lloyd-Dodd, E. H. H., L.R.C.P.&S.L, L.M., Second A.M.O., Leavcsden
Mental Hospital, Woodside, Leavesden, Watford, Herts.

Proposed by Drs. F. A. Elkins, T. W. Hills, and R. Worth.

Kerr, Felix Arthur, M.B, Ch.B.Glasg., A.M.O., Rubery Hill Mental
Hospital, Birmingham.

Proposed by Drs. T. C. Graves, C. B. Forsyth, and A. Miller.

Wilson, James Leitch, M.B., Ch.B.Edin., A.M.O., Brooke House, Clapton,
E. 5.

Proposed by Drs. G. H. Johnston, R. H. Cole, and R. Worth.

Jackson, John Luke, M.B., Ch.B.Belfast, Senior A.M.O. and Deputy Super¬
intendent, Hants County Asylum, Knowle, Fareham.

Proposed by Drs. H. Devine, F. E. Stokes, and R. Worth.

Paper.

“The Minimal Requirements for a Small Clinical Laboratory.” By W. G.
Thomson, M.A., M.B., Ch.B., D.P.H. Aber., Assistant Medical Officer, County
Mental Hospital, Cheddleton, Leek.

I have been asked to outline the apparatus necessary for the setting up of a
small laboratory in an asylum and to give the probable cost. I hope those of you
who already have a laboratory in full working order will bear with me while 1 try
to show others that the fitting up of a small laboratory where useful clinical and
pathological work could be done need not be an elaborate or costly affair.

The late Sir Robert Morant once said—he was talking of general hospitals, but
his words apply equally to asylums—that the day of the two hours to a round had
gone and the day of two hours to a bed had come. If there be any truth in his
words, there is no doubt that laboratory work must have a share in these two
hours. How big a share it is to have I do not try to estimate, nor am 1 concerned
with other questions that have been discussed—for example, whether one ought to
have centralised laboratories or not. Asylums are usually self-contained units in
most things. Why should they not be self-contained in this respect—that each
should have its own laboratory ?

The great thing is to get a start—a small laboratory will lead to a larger and
more fully equipped one, where we may have at least one man working on his own
local problems, and possibly trained men working on the bigger general problems.
Much material is undoubtedly going to waste in asylums, and the setting up of a
laboratory is an economic question. It would help indirectly to keep down the
rates. To take a concrete example, we had here, some years ago, a small epidemic
of typhoid which involved about forty cases. From the nature of the outbreak and
its course we came to the conclusion it was due to a carrier. We had to rely
almost entirely on outside help for the detection of the carrier. This help was
most costly, and, in the aggregate, cost us more than the setting up of a laboratory
would have done. There is also the question of dysentery, which is endemic in a
large number of asylums. This disease, in our experience at least, causes more
chronic ill-health amongst the patients than almost any other. This means the
loss of many working days—days which might be saved if we were able readily to
detect carriers. But much patient work will do this, and it can be done, I feel
sure, even in a small laboratory.

At this asylum (Cheddleton) we made a modest beginning with laboratory work.

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We found an unused room. It was a dull room, so we had it painted white to give
us more light. We had a bench made, bought an incubator, centrifuge, and sorfie
glassware, and as we already had a microscope we were almost ready to start.
The bench we covered with plate glass. This glass had been in the institution
for some years. I do not recommend those of you who are thinking of setting up
a laboratory to cover your benches with glass. It is an unnecessary expense. A
more economical way is to impregnate plain white wood with a solution of copper
sulphate and potassium permanganate. This gives a smooth black surface after
it has been polished with linseed oil. It is not corroded by ordinary acids.

A reliable microscope would cost at the present time .£30 to /40. One must
have an oil-immersion lens, and it is the most expensive item. Our bench cost us
little. We had it fitted up by our own workmen and patients, who also fixed up
for us a sink and shelves. The fitting up of the shelves, sink and bench cost us
about £5.

We managed to obtain two cupboards, a couple of tables and a chest of drawers.
These we found unused in a store-room, and there are in most institutions similar
articles to be found. I cannot estimate the cost of these things. All our glass¬
ware, other than bottles which we found in the dispensary, we bought from a firm
which deals in laboratory outfits. Much expense can be avoided by using for
many purposes ordinary dispensary bottles, especially those with glass stoppers.
This glassware, by which I mean flasks, test-tubes, beakers, Petri dishes, funnels,
watch-glasses, rods, etc., did not cost us more than ,£20. We had one bad bargain.
Our miscroscope slides we had to buy at a time when the Government would allow
them to be sold only in large quantities, with the result that we have enough to
last us for years. This difficulty should not occur again. Our incubator cost us
£21 and our centrifuge £-]. Both are electrically driven—in fact all our apparatus
which require power or heat are worked by electricity. Although this is possibly
not the best way, it works very well. We had a few initial difficulties with the
wiring. I am led to believe that incubators controlled by gas or paraffin are
cheaper, and that a water-driven centrifuge is more steady. We did not invest in
a steam steriliser, but we manage to work with a hot-air steriliser and a double-
bottomed rice-cooker, with the occasional use of the milk-pan steriliser in the
main kitchen. Our hot-air steriliser cost us £\t, and a reliable balance, which is
essential, cost us £2 10s. These were the heaviest items of expenditure on the
bacteriological side.

Our stocks of media and stains we have gradually acquired. We spread the
whole cost over some months and the drain has not been heavy. We spent about
£7 10 s. in buying peptone, agar, sugars, and some of the commoner stains and
chemicals. Our cultures we obtained from the Lister Institute at a nominal cost.
In addition we have isolated from our own cases strains of typhoid, dysentery and
other organisms.

At an outside estimate all the things I have mentioned from the start cost us
^80, if we exclude our bad bargain in the slides and the microscope.

On the histological side we bought a microtome and a paraffin bath. The bath,
which is worked electrically, cost us £g, and the microtome £7 15s. On the
clinical side we have simply added a few instruments to those already in use. A
htemocytometer, htemoglobinometer, ureometer, and albuminometer can be bought
for £5.

It is not very interesting to listen to the reading of a catalogue of apparatus and
its cost. I have had prepared a fairly complete list of things necessary for fitting
out a laboratory, and if anyone would like a copy I have one here. Our laboratory
as it is at the present time cost us .£115. I think now if we had to do the whole
thing over again that we could save on this amount.

We are now dealing with all the ordinary routine work, by which I mean the
examination of sputum, blood, freces, spinal fluid, stomach contents, throat swabs,
urine, etc. We have eliminated typhoid, and are working on our own dysentery
problem and on acidosis. We also cut and stain our own sections from
post-mortems. Much of the burden of routine work has been taken off our
shoulders by our laboratory attendant, whom we trained ourselves. He is also our
post-mortem room man.

It is an additional interest in our work that we are now able to follow up our
cases in the laboratory and to see the methods by which full diagnoses are reached.

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We have an incentive to keep ourselves abreast, at least in regard to what I
might call the purely physical side of our cases.

1 know that the difficulty in the way of many asylums has, in the past, been, not
the provision of the necessary apparatus, but the lack of medical officers who
have the training to take up even simple bacteriological work ; but after all this
need not be a difficulty. Study-leave is now given in order that a man may take a
course in psychiatry. Why should leave not be given so that a man may take a
short course, say of three months, in practical bacteriological and pathological
methods ? Medical superintendents, however, ought not to expect too much from
men who are not fully trained. We do not want to divorce the purely clinical side
from the other sides of medicine, at any rate in the earlier stages of investigation,
if at all.

I have read in the Journal—I think in the report of the annual meeting of 1914
—that many asylums were then without a laboratory. I do not know how condi¬
tions have altered since that time, but the war has shown us the necessity of having
a complete medical organisation in each unit, and that organisation is not complete
without a bacteriological laboratory.

The President, in calling for a discussion, said the paper was very much to the
point, brief, and yet full of information of great value.

Dr. Pasmore desired to compliment Dr. Thomson on a very able paper, and on
the lucid and terse manner in which it was put together. He was sure those
medical superintendents who had not a fully equipped laboratory in their establish¬
ment would be guided to some extent by the estimate of cost which Dr. Thomson
had here laid down. He quite agreed with the author that the clinical work ought not
to be divorced from the laboratory. If one started a laboratory in a mental
hospital, the tendency was often to have a separate pathologist, not altogether a
good thing, because such an official did not come into contact with the actual
clinical work, and hence was not able to view the work from the two sides.

Dr. A. Helen Boyle said she had been much interested in Dr. Thomson’s
paper from the personal point of view. She had been wanting to get a little place
in connection with Lady Chichester Hospital, and she would be glad to see Dr.
Thomson’s list afterwards, to note exactly what he regarded as the requirements.
She was amazed at .£115 being sufficient, and the author appeared to think it
might be done even for less than that. At the present enormous cost of everything,
even of a table, she would have thought it would have been much more. But,
probably Dr. Thomson had had more assistance at hand than she would at her
hospital. A small laboratory on the spot was an enormous help in any form of
clinical work. (Dr. Thomson: The .£115 does not include the microscope, which
is a great additional expense.)

Dr. Tom A. Williams (Washington, D.C.) remarked that considerable
experience in the differentiation of the work of the laboratory and that of the
wards had existed in America, where the policy had been one of centralisation,
and the co ordination of many activities in many asylums into one institution in
the same State—a teaching place—generally administered by someone who was a
professor in one of the Colleges. This professor had under his control a central
laboratory, in which nearly all the work of that State was carried out. In a
laboratory of that sort were employed many assistants, some of them highly
specialised, and some others who were desirous of specialising in laboratory work,
others in clinical work. It was really advanced research, and had been responsible
for a definite increase in knowledge in the specialty. The drawback had been that
there was a strong tendency towards specialisation, so that the clinical men in the
asylums were liable to neglect the operations in the laboratory, and thus fail to
realise the importance of that side of the work. This tendency had been largely
overcome in the following way: these men were all, in turn, sent for three months
to the central institute for special training in laboratory work, methods and aims,
from which they returned to their own institutions, so that they might leaven the
rest of the staff there with the knowledge acquired. Further, from the central
institution were sent, periodically, men specially expert in different spheres of
inquiry, either to instruct those in the remote institutions, or to study some special
problem, such, for instance, as an outbreak of asylum dysentery. In the course of
the study of that special problem they enlisted the sympathy and services of the

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staff, and in that way they proved themselves to be very valuable educationally.
In the State of Massachusetts, where that was most advanced, and in the State of
New York, where it was now nearly as advanced, as well as in the State of
Pennsylvania, it had led to the establishment of such laboratories as Dr. Thomson
referred to in his paper in every institution, in which the immediate, urgent and
necessary routine work was done by members of the asylum staff. It had led,
further, to the co-ordination of the activities of the central institution in work
which demanded specialised knowledge and training for its solution. Hence in
most of these smaller laboratories there was no microtome, no provision for
histological investigation, but the material for such was sent to the central
institute, where it was worked up. The asylum laboratory became mainly
bacteriological and serological, because problems of that kind must be solved on
the spot by the clinical men who were interested. In that way smaller laboratories
could be established, even for less money than Dr. Thomson’s estimate, for the
necessary routine work of a mental hospital.

Dr. J. Middlemass wished, in a word or two, to express his appreciation of Dr.
Thomson's paper. All would agree there were many cases, apart from epidemics,
which required bacteriological examination in an asylum. Pathological examina¬
tions on the spot were of the greatest benefit, as he knew from his own experience—
for instance, in examinations of the cortex of the brain. Such an examination had,
in many instances, cleared up a doubtful case. Every asylum should possess
facilities for a study of that kind : it was very simple, and did not need more than
a couple of days for determining whether a case was one of general paralysis.
Every asylum would be the better for having some such laboratory as Dr. Thomson
had outlined in his paper.

Luncheon.

Members were then kindly entertained to luncheon by Dr. and Mrs. Menzies,
whose generous and genial hospitality was acknowledged before rising from the
tabic by a few graceful words from the President.

AFTERNOON SESSION.— July 2 7 th.

Thanks to the Retiring President and Officers.

Lieut.-Col. E. \V. White said a very pleasant duty had been assigned to him,
one which he felt he was unable to carry out in fitting and adequate terms. It
was that of proposing a very hearty vote of thanks to the President and other
officers of the Association for the way in which they had discharged their several
duties during the past year. The President, Dr. Bedford Pierce, whom they all
admired, and whose career they had watched for years past, until he attained his
present position, for which he had always been felt to be well fitted, had filled the
post in a most thoroughly conscientious and able way, and to the entire satisfaction
of the members. He had thereby added, if possible, lustre to the Association,,
with which he had been closely connected for many years, from the days of Hack
Tuke onwards. He had filled the posts of chairman of various Committees, and
had done a great deal of detail work for the Association.

With regard to the other gentlemen covered by this resolution, the Association
was blessed with very good officers, who denied themselves in every way in order
to discharge faithfully the duties of their offices. Sometimes the work had been
done under great difficulties, because we were only as yet just emerging from the
effects of the great war. Still, the duties had been carried out in a way which
must have given those officers a great deal of satisfaction when they reflected
upon it.

Dr. Beveridge Spence, in seconding the motion, said that after the appreciative
and eloquent speech of Col. White it was not necessary for him to add much.
Still, he would like to say that he had been struck that morning, as all through the
year too, with the eminently business-like way in which the President transacted
the Association’s business; he always interpreted difficult points clearly, and
lucidly expressed the salient features for the benefit of the meeting. As to his old
friends, Dr. Miller and Dr. Chambers, and the others who occupied subordinate
positions, they had continued their activities to the full satisfaction of the Associa¬
tion generally, and members were sure they were deeply occupied in promoting

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the good of the Association in every way. He seconded the motion with much
pleasure.

The resolution was carried by acclamation.

The President (Dr. Bedford Pierce) said he would be lacking in feeling if
he did not greatly appreciate the kind words which had been uttered by the
proposer and seconder concerning the way in which he had discharged his duties
as President. The work had been very easy to him, things had gone smoothly,
and he thought the Association had during the past year re-established itself after
the trying time of the war. He realised that the chief reason of that was the
devotion of the officials of the Association ; they had been loyally behind him all
through in all he had done, so that very much of what had been said of him really
applied to them. He did not think he need say more than that when he took up
this office he relied upon the support of the Association. That support he had
had, and in yielding up the office he thanked members for the very kind way in
which he had been helped throughout in the duties he had tried to discharge.

His next—and his last—duty as President was to ask Dr. Menzies to come
forward and occupy the chair as President for the ensuing year. He did not think
Dr. Menzies would like him to say very much in introducing him; indeed, if he
were to do justice to the occasion he would be taking up time which would be
more profitably spent in listening to the new President’s address. There could
be no doubt that Dr. Menzies was a man whom the Association would be delighted
to honour. He was worthy of the post; his learning, his experience and his
culture fitted him for it; and all very sincerely welcomed him in taking up his new
duties as President.

Dr. W. F. Menzies was invested with the Presidential insignia by the retiring
President, and took the Chair.

Presidential Address.

The President then delivered his address on "The Mechanism of Involutionary
Melancholia ” (see p. 355), following which the meeting adjourned till the following
morning at the Town Hall, Buxton.

Garden Party.

On the same afternoon the President and Mrs. Menzies entertained the members,
ladies and guests to a garden party held at the Hospital. There was quite a large
company, including members of the North Staffordshire branch of the British
Medical Association and of the Hospital Committee, and residents in the neighbour¬
hood. The gathering was a happy one, the weather being beautifully fine and the
grounds were greatly admired. A central feature of the proceedings was the pro¬
gramme of music played both before and after tea by the remarkably efficient hospital
orchestra. Dr. Menzies conducted the orchestra, of which he has good reason to
be justly proud.

Wednesday, July 28th.

The morning and afternoon sessions were held at the Town Hall, Buxton, Dr.
W. F. Menzies in the chair. At the morning session an address was given by Dr.
Tom Williams (of Washington, D.C , U.S.A.) on “ A Discussion of some Deter¬
minants of Morbid Emotionalism,” and a discussion on “ Psycho-analytical
Teachings as Illustrated in the Psychoses ” was opened by Dr. W. H. B. Stoddart,
whose paper was entitled “ A Brief Resume of Freud's Psychology.” Following
this, Dr. C. Stanford Read read a paper on " Homosexuality,” Dr. W. Rees
Thomas on " Sadism and Masochism,” and Prof. W. Brown on “ Criticism of
Present-day Psycho-analysis.” In the absence of the author, Dr. Bedford Pierce
read Dr. H. G. Baynes’ paper on " Psycho-analysis.”

After luncheon the subject was freely discussed, members expressing their views
without reservation and not infrequently in a singularly candid manner. Prior to
calling upon the various openers for their replies, the President read an interesting
letter on Freud’s psychology which had been addressed to the Association by
Prof. Friedlknder, of Freiburg-i.-Baden, Germany. Owing to the temporary limita¬
tions of the size of the Journal it is necessary to hold over these contributions,
together with a report of the discussion, until the January number.

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Reception in the Town Gardens, Buxton.

The Mayor and Corporation of Buxton and the Buxton and High Peak Medical
Society entertained members, ladies and guests of the Association in the Town
Gardens to tea at 5.30 p.m. on July 28th. Subsequently members had an oppor¬
tunity of visiting the Town Baths and Devonshire Hospital, where the modern
installation for electro-therapeutic treatment was much admired.

Annual Dinner.

The Annual Dinner of the Association was held at 8 p.m. on Wednesday,
July 28th, at the Palace Hotel, Buxton. The function was well attended, the
usual “ toasts ” honoured and a happy evening spent. Ladies were included among
the guests and it is hoped that their presence may bean annual event in future.

Owing to inclement weather the excursions arranged for the two following days
had to be abandoned.

IRISH DIVISION.

The Summer Meeting of the Irish Division was held on Thursday, June 24th,
1920, at Purdysburn Villa Colony, Belfast, by the kind invitation of Dr. Graham.

Members present: Dr. Graham (in the Chair), Dr. Nolan, Dr. J. O’C. Donelan,
Dr. Mills, Dr. Lawless, Dr. Patrick, Dr. Leeper (Hon. Secretary).

Letters of apology for unavoidable absence were received from Dr. Colles, K.C.,
Dr. Gavin, of Mullingar, Dr. Martin, of Letterkenny, Lt.-Col. W. R. Dawson and
Dr. O’Doherty, Omagh.

The minutes of the previous meeting were read and signed.

A great deal of correspondence in connection with the General Nursing Council
for Ireland was read, and it was proposed by Dr. Mills, seconded by Dr. Patrick
and unanimously approved:

“That Dr. Nolan and Dr. J. O'C. Donelan be nominated by the Division as
representatives of the Irish Division of the Medico-Psychological Association on
the Sub-Committee of the General Nursing Council for Ireland.”

A ballot for the election of an ordinary member was next proceeded with, Dr.
Patrick and Dr. Mills being appointed scrutineers. The Chairman subsequently
declared that Dr. J. P. Boland, Assistant Medical Officer of Ballinasloe Asylum,
was elected a member of the Association.

The meeting next proceeded to consider important matters in connection with
the Nurses’ Registration Bill, and a letter was read from the Chief Secretary in
reply to the communication addressed to him by direction of the Autumn Meeting
of the Medico-Psychological Association. The following is the text of the letter :

Chief Secretary’s Office,
Dublin Castle;

June 12th, 1920.

Sir,—Referring to your letter of April 21st last on the subject of the Constitu¬
tion of the General Nursing Council for Ireland, I am directed by the Lord
Justices to acquaint you, for the information of the Irish Division of the Medico-
Psychological Association of Great Britain and Ireland, that the question of
appointing a representative of the Asylum Medical Service or the mental nurses
in Ireland will be considered in the event of a vacancy arising on the Nursing
Council, or when the Council is being reappointed at the end of three years, if no
vacancy occurs in the meantime.

I am to add that, as you are no doubt already aware, two representatives of the
Irish Division of the Medico-Psychological Association have been invited to act on
a special Sub-Committee of the General Nursing Council appointed to draft rules
for the admission of mental nurses to the Register.

I am, Sir,

The Hon. Secretary, Your obedient Servant,

Irish Division, C. M. Martin-Jones.

Medico-Psychological Association of

Great Britain and Ireland,

James’s Street, Dublin.

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The Hon. Secretary was directed to write to the Chief Secretary acknowledging
the receipt of his letter, and stating that the Irish Division was glad to hear that
the first vacancy upon the Council was to be filled by a representative of the
medical or nursing staffs of the asylums.

Questions in connection with the failure of the Government to give the asylum
service any representation upon the General Public Health Council of Ireland were
discussed.

Dr. Lawless sought the opinion of the members as regards the position of the
staff in his asylum, the newly appointed Board having refused to pay the staff
salaries owing to some temporary deadlock. Dr. Lawless received the advice of
the members.

Subsequently the members visited the Villa Colony, the workshops and other
features of interest in connection with the Institution.

Dr. Lawless having been called to the Chair, a cordial vote of thanks to
Dr. Graham for his kindness and hospitality and for the very interesting day he
had given to the members was proposed by Dr. Nolan, seconded by Dr. Donelan,
and passed with acclamation.

The following letter has been circulated (vide Report of Quarterly Meeting,
P-66):

MEDICO-PSYCHOLOGICAL ASSOCIATION OF GREAT BRITAIN

AND IRELAND.

11, Chandos Street,

Cavendish Square,
April 2nd, 1920.

Dear Sir,

The Council of the Medico-Psychological Association of Great Britain and
Ireland is most anxious that the scope and usefulness of the Association shall be
extended, so that it keeps fully abreast of modern developments, and expresses
the aims and aspirations of younger members. At the present time new clinics
are springing up all over the country under the Ministry of Pensions, and it is
believed that it will not be long before the Ministry of Health will provide early
treatment for civilians suffering from mental and nervous disorders. This new
departure was urged by the Medico-Psychological Association in 1914 and again
in 1918, and we believe the Association can and should assist in carrying out this
reform successfully.

The activities of the Association were necessarily curtailed by the war, but its
members continued to render striking service to medicine during this time in
divers fields of work, and now that a new era is at hand, the Council trusts that
the Association may once again fulfil its proper function in promoting renewed
interest in psychological medicine.

It is of the first importance that all the young men freshly returned from service
under war conditions, especially those who have been engaged in research work,
or in the treatment of nervous and mental disorders, should become members of
the Association, as it is to them we must look for inspiration and progress. Our
membership should include all engaged in psychiatry, not merely those interested
in the welfare of the insane, but all physicans devoting their energies to the study
and treatment of nervous and mental disorders.

We believe the Association can render signal service to the community in
facilitating the interchange of ideas, in stimulating research, and in publishing in
its journal reports of success and of failure in treatment.

The object of the letter is to ask all our members to encourage anyone they
know to be interested in psychiatry, whether engaged in hospitals, clinics, private
institutions, or pension boards, to apply for membership. An appeal of this kind
can, however, hardly be attended with success unless it is found to be worth while
to join the Association.

The following facts may be mentioned :

(1) The Medico-Psychological Association has a membership extending through¬
out the whole of Great Britain and Ireland.

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(2) Through its Standing Committee it has done, and is still doing, most
valuable work. The Parliamentary Committee watches all new legislation. The
Educational Committee successfully stimulated University Authorities to establish
special diplomas in Psychological Medicine. It controls the Examinations for
the Nursing Certificate, which has been of such striking value in improving the
training and status of mental nurses.

(3) Special Committees are frequently set apart to initiate new developments,
and the Association has a successful record of work carried out in this way.

(4) The Journal of Mental Science takes a high place in the literature of
Psychological Medicine. Under new conditions it will again grow in size and
importance. Besides publishing original articles it contains an excellent abstract
of current literature. No one interested in the subject can afford to ignore the
Journal of Mental Science, whilst its pages have not rarely first brought to the
notice of the public a new worker in psychiatry who subsequently has become
distinguished.

But we believe the chief value of the Association lies in the facilities it provides
for the interchange of ideas and the discussion of difficulties and problems.
Further, there is a manifest gain from the personal intercourse at the meetings of
members united by a common bond of interest. The Association is a democratic
body, innovations calculated to enhance its usefulness are welcomed, and in the
new order of things that has commenced the signatories to this letter believe that
the members generally will gladly support new developments likely to advance the
objects of the Association.

Yours very truly,

{Signed) Bedford Pierce, President.

James Chambers, Hon. Treasurer.

Reginald Worth, Hon. Secretary.

P.S. —Members are elected at the General and Branch Meetings of the Associa¬
tion. Forms of application for membership can be obtained from the Hon.
Secretary, Dr. R. Worth, Springfield Mental Hospital, Tooting, London, S.W. 17,
and should be returned to him a month before the meeting at which election is
desired, so that the names may appear in the Agenda.

MINISTRY OF HEALTH: FIRST ANNUAL REPORT (1919-20).

Lunacy and Mental Deficiency (Transfer of Power Order), 1920. (*)

It was always intended that the Ministry of Health should become the Depart¬
ment responsible for the care and treatment of lunatics, but the Home Secretary's
powers could not be transferred in their entirety, as they included powers in
relation to criminal lunatics which could not be dissociated from the general
administration of criminal law. Section 3 (2) (6) of the Ministry of Health Act,
1919, accordingly provided for the transfer by Order in Council to the Ministry of
all or any of the powers and duties of the Home Secretary under the enactments
relating to lunacy and mental deficiency. A draft Order in Council was prepared
in consultation with the Home Office and laid on the table of both Houses in the
autumn of 1919. But certain minor amendments proved to be necessary, and a
fresh Order had to be laid at the beginning of the present Session, with the result
that the actual transfer of powers did not take effect until May 17th, 1920. This
Order in Council marks an important step in the process of centralising all health
administration in a single department, and the Minister of Health is now responsible
to Parliament for the administration of the Board of Control. No change is
made in the constitution or procedure of the Board, but the effect of the Order is
to allow of the treatment of mental diseases being co-ordinated more closely with
the treatment of other forms of disease than would have been possible while the
responsibility for the administration of the Lunacy and Mental Deficiency Acts
rested with the Home Secretary.

(>) Statutory Rules and Orders, 1920, No. 809. [Price id. net.]

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500 NOTES AND NEWS. [Oct.,

TREATMENT OF INCIPIENT MENTAL DISORDER.

Dr. Addison, the Minister of Health, presented the Ministry of Health (Miscel¬
laneous Provisions) Bill in the House of Commons on Monday, August 16th.

Clause 10 relates to treatment for incipient mental disorder. It sets out that:

"(1) Notwithstanding the provisions of any Act, a person shall not, if the
required conditions are complied with, be liable to any penalty for receiving to
board, lodging, or taking charge of for a period not exceeding six months, or such
longer period not exceeding in all twelve months, as may be approved by the
Minister, and whether for payment or not, any person suffering from mental
disorder which is incipient in character and of recent origin, but not being a
person who has been certified as a lunatic under the Lunacy Acts, 1890 to 1911, or
in respect of whom an order has been made under the Mental Deficiency Act,
1913. Provided that nothing in this section shall authorise any person who has
been received into any institution, home, or house under this section to be detained
therein if he delivers to the superintendent or other person, by whatever name
called, having the charge of the institution, home, or house, or sends by post to
the Minister, notice in writing that he desires to be discharged therefrom.

“ (2) The required conditions for the purposes of this section are as follows :
( a ) The institution, home, or house in which the person is received must be
approved for the purposes of this section by the Minister. ( b) No such person
shall be received into the institution, home, or house except with his previous
consent in writing and except on a certificate in writing by two duly qualified
medical practitioners to the effect that that person is reasonably likely to benefit by
treatment therein, (c) The superintendent or other person, by whatever name
called, having charge of the institution, home, or house, shall on the demand of
any person having authority to inspect the institution, home, or house produce all
such written consents and certificates as aforesaid, (d) The reception under this
section of any person into the institution, home, or house shall be reported to the
Minister by the superintendent or other person aforesaid.

"(3) Any institution, home, or house approved by the Minister under this
section shall be periodically inspected by officers appointed for that purpose by the
Minister.

" (4) The Minister may make regulations for the purpose of carrying this
section into effect.”

The maximum penalty for a contravention of the section is a fine of ,£100 or
imprisonment for six months, or both fine and imprisonment.

Regarding Dr. Addison’s proposals in this connection, the British Medical
Journal, August 28th, makes the following observations:

“ Among the medley of clauses in Part 2 of the Ministry of Health (Miscel¬
laneous Provisions) Bill, Clause 10, dealing with incipient mental disorder, alone
has the appearance of a step in constructive legislation. This lays dow'n that,
provided the required conditions are complied with, it shall not be an offence to
receive for six months (or such longer period, not exceeding in all twelve months,
as may be approved by the Minister of Health), and whether for payment or not,
any person suffering from mental disorder which is incipient in character and of
recent origin, but not being a person who has been certified as a lunatic, or in
respect of whom an order has been made under the Mental Deficiency Act, 1913.
Attached to this is the proviso that nothing in the clause shall authorise anyone
who has thus been received into an institution, home or house, to be detained there
if he delivers to the person in charge or sends by post to the Minister notice in
writing that he desires to be discharged. Stated shortly, the clause enables a
person suffering from incipient mental disorder, but not certified under the Lunacy
Acts, to be received, with his own consent, in an institution approved by the
Minister, for a period of six months, without exposing those who receive him to
penalties under the Lunacy Acts.

“ The required conditions are: ( a ) The institution, home, or house must be
approved for the purpose by the Minister; ( 4 ) no person shall be received therein
except with his previous consent in writing and except on a written certificate by
two medical practitioners to the effect that he is reasonably likely to benefit by
treatment therein ; (c) the superintendent or other person in charge shall, on the
demand of anyone having authority to inspect the place, produce all such written

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consents and certificates ; (rf) the reception under this clause of any person shall
be reported to the Minister by the person in charge. Lastly, it is provided that
any institution, home, or house approved by the Minister shall be periodically
inspected by officers appointed by him for that purpose, and that the Minister may
make regulations for carrying the clause into effect.

“ These provisions follow roughly the lines advocated severally by the Board of
Control in 1917, by a special committee of the Medico-Psychological Association,
whose interim report appeared in November, 1918, and by the Guildhall conference
on asylum committees in February, 1919. Clause 10 approximates most closely
to the proposals of the Board of Control, of which a full account was given in our
issue of April 10th, 1920, at page 515. It is to be observed that this clause takes
the form of an amendment to, and not a comprehensive revision of the Lunacy
Acts. It is purely permissive in character, leaving the whole question of the
provision of accommodation and treatment for these cases to the interplay of
demand and supply: whereas the Medico-Psychological Association urged the
need of imposing upon local authorities the duty of providing the requisite treat¬
ment either directly or through voluntary organisation, and insisted that there
should be special staffing and special management for these institutions. If,
however, Clause 10 is read with Clause 11 (which we discuss elsewhere) it will be
seen that some provision is made for development in this direction. We may
note also that Clause 10 provides for cases of mental disorder ' incipient in
character and of recent origin.’ This seems a less elastic definition than that
offered by the Board of Control, which implied a distinction between cases incipient
in character and those of recent origin.

“The Bill states that inspection will be by ’officers appointed for that purpose
by the Minister,’ but until the regulations are made known it is not clear whether
the new arrangements contemplated for incipient and recent cases of mental
disorder are to be administered and supervised, on behalf of the Minister, by the
Board of Control or not. Many of those who have pressed for this reform have
insisted on the importance for its success of separating these arrangements entirely
from the ordinary lunacy administration, whether central or local, for fear that any
association with it would fatally prejudice the new method in the eyes of the
public. A memorandum on the Bill, published this week by the Ministry of
Health,(') implies that this separation will be brought about under the operation
of Clause 10. * The importance of early treatment of these cases,’ it says,

‘ wholly dissociated from the machinery of the Lunacy Acts, is now generally
recognised, and the powers given by the clause will be especially useful in cases of
shell-shock and similar nervous disorders.’ Unless the public can be induced
voluntarily to make use of the facilities proposed at the very onset of the disorder,
and before things have come to such a pass that something drastic has to be done,
they will fail to attain one of the most important objects in view, which is to arrest
the disorder and restore the normal balance.

“ The proposed method of detention under this Bill is in its essentials an extension
of the ‘voluntary boarder’ system, and the formality of a written application for
admission is still required as a necessary step previous to reception. Such a
requirement often deters the patient from making use of the present provisions
and we regret its retention. It would be better, we believe, to assume that a
person desiring treatment under this clause consents by implication to such
restriction of his liberty as is necessary for his treatment, subject to the provision
that he can at any time resume his liberty by giving notice in writing to that effect.
This is practically the way in which cases of mental disorder occurring in patients
in general hospitals have been dealt with informally in the past without difficulty
and without abuse.

“ It is satisfactory to note that provision is made for the extension of the period
of treatment from six months, as originally foreshadowed as the standard period,
to one of twelve months, with the approval of the Minister. Six months is sure
to be inadequate for complete recovery in many cases suitable for treatment under
these provisions. It is, however, not quite clear why a person who has once been
certified under the Lunacy Acts and has recovered should be debarred from taking
advantage of these provisions in the early stages of some later onset of disorder.”

(') Cmd. 898. H.M. Stationery Office. Price id.

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TREATMENT OF INCIPIENT MENTAL DISORDER.

(Vide Brit. Med. Journ. September nth, 1920.)

Sir, —With reference to your observations in the issue of the Journal of
August 28th upon Clause 10 of the Ministry of Health (Miscellaneous Provisions)
Bill, if you will allow me to say so, the criticisms of your last two paragraphs
single out what appear to be the weakest points in the new provisions.

(1) Any extension of the "voluntary boarder" principle I regard as a mistake.
Insistence on the previous consent in writing of the person to be received will
often act as a deterrent. Then there are the cases whose mental state is so
disordered that they are not in a position to give or withhold consent. The
disorientation, the incapacity to form a judgment or take a decision, are evident, yet
the disorder may fairly be considered as “ incipient in character and of recent
origin.’’ Is the door of a psychiatric clinic to be “ banged, bolted and barred ”
on these ? If so, where is the medical student of the future to study them ? It
seems unfair to both parties to compel them to journey out to the asylum.

(2) As regards the provision by which a person who “ has been certified as a
lunatic " is ineligible for treatment under the new conditions, is it possible this
can mean that a person shall not be admitted to the new institutions and homes
concerning whom there are in force certificates under the Lunacy Acts? Upon
first reading the clause, as a plain man accustomed to understand plain English
“as she is wrote," I naturally put the same interpretation as you do upon this
proviso. I fear we must assume that this interpretation is correct, notwith¬
standing that it might well puzzle all the notaries in Padua to explain why
persons aforetime certified under the Lunacy Acts, and recovered, are ineligible
under the new conditions—are to be shuffled ofF as encumbrances on the march of
progress. Those of us who have dealt with these cases—who are aware that
large numbers of them need not have been certified under the Acts had the
provision now contemplated been in existence, and who know that, in case of
relapse, recertification and reconsignment to the asylum would be unnecessary
were the provision in existence—anxiously await the reasons for this exclusion.
Are these unfortunates, like the Board of Control, to whom access to the new
institutions, etc., would be barred by some, looked upon as bespattered with
unsavoury oils from the " machinery of the Lunacy Acts—as 1 damaged goods ' ” ?

Doubtless an early meeting of the Medico-Psychological Association and of the
National Association of Mental Hospital authorities will be called to consider the
provisions of Clause 10.—I am, etc.,

Edwin Goodall,

August 30th. Cardiff City Mental Hospital.

HOSPITAL TREATMENT OF THE PSYCHOSES AND PSYCHO¬
NEUROSES.

By Edwin Goodall, C.B.E., M.D., F.R.C.P.Lond.

(Abstract.)

The following suggestions are concerned particularly with patients other than
in the Metropolis who are either of the usual hospital class or not able to pay
more than from two to five guineas a week, most of them only able to pay such
fees for about six months. Under the designation "psychoses” would be com¬
prised the various varieties of mental disorder, mainly in an early phase. The
psychoneuroses would be illustrated by the borderland states, with mixed mental
and “nervous” manifestations; psychasthenia or neurasthenia, with obsessions or
imperative ideas; morbid doubts and fears; tics, with psychical perversion;
psychoses associated with disorders such as Graves’s disease or chorea; mixed
nervous and psychical disorders after mental or physical shock; psychoses
associated with minor epilepsy.

How could they be comprised in such a scheme as has been sketched in the
Interim Report of the Consultative Council on Medical and Allied Services?
On consulting the Report it will be seen that the only reference made to mental
disease is under “Supplementary Services” (pars. 14 and 74). Amongst these

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services come “ hospitals for curable or incurable mental disease.” So that the
patients now referred to would merely be provided for in a supplementary fashion,
together with, for instance, cases of tuberculosis, of infectious disease, and of
epilepsy suitable for colony care. Incurable mental disease could be adequately
provided for thus, but not curable. The psychoses and psychoneuroses together
constitute a vast and oppressive liability, which, I maintain, cannot be discharged
through the medium of a mere supplementary service.

One may conceive cases of the psychoses and psychoneuroses as occurring in a
certain area, and provision being made for them under the general scheme of the
Interim Report as follows (existing buildings, modified or enlarged, to be used for
the present; the psychiatric clinic would require to be a new building) :

(a) In a rural district, where the most modest requirements of an indoor clinic
or hospital are scarcely available and the needs of patients would have to be met
under the next heading.

( b ) In a small town able to furnish a building worthy to rank as a hospital
(primary centre). Here there would be comparatively modest equipment for
diagnosis, clinical laboratory work, and medical and surgical treatment.

(c) In a large town containing a hospital in an adequate sense, with visiting
medical staff, some with training in special directions; a resident medical officer
or two; some of the nurses specially trained in various directions, with one or two
capable of conducting, with some tuition, a class of Swedish exercises; with
masseuses; with laboratory facilities of a fairly extensive kind and technical
apparatus; with out-patient department—in fact a hospital equipped with every¬
thing entitling it to rank as a secondary centre.

(d) In the town wherein is situated a medical school, with its associated
hospital, research and laboratory workers, teaching facilities, and consultants—
the teaching or tertiary centre to wit; the ne plus ultra when the lacking clinic
in psychiatry, complete internally, with its out-patient department in association
with other like departments of the hospital, shall have been established.

Those who have experience, be they general practitioners or specialists, of the
difficulty and inappropriateness of dealing with—I will not say treating—these
patients in their homes will fully appreciate how much the application of the
three-centre scheme will mean to them. In my judgment the first desideratum
is to get them away from home surroundings and from relatives. Is there any
class of invalid to whom this applies with equal force? Solve this difficulty by
providing for these cases on the three-centre system, and their treatment is at
once placed on a sound footing, and the haunting fear of the alternative to
home—the asylum—will fade, treatment will commence in reasonable time, and
less will be heard of the need for extending asylums. In making such provision
regard must be had to special requirements. Whether cases of the psychoses and
psychoneuroses are received under ( b ), (c) or ( d ) of the above scheme, they will
require facilities tinder the following headings:

A room or ward so arranged, supervised and administered, that means of self-
injury are reduced to a minimum; one or more single rooms for isolation; a
nurse or nurses, trained in mental disorders (preferably with general training also;
the combination is more and more to be found) ; one or more masseuses, according
to requirements; facilities for open-air rest in bed, for regular weighing; douches,
open baths, available for prolonged warm-bath treatment—under (d) baths main¬
taining a constant level and temperature; a garden for exercise and occupation ;
facilities for indoor occupation, especially handicrafts—under (<f) suitable shops,
sewing-room and gymnasium, and other facilities for treatment under this special
heading, which need not be specified here.

As regards diagnosis and medical advice, the principal and second medical
officers of the nearest public mental hospital should be available for consultation,
as also the director, or one of the staff, of the nearest psychiatric clinic. I would
suggest that the domain of the psychoses and psychoneuroses is quite peculiarly
one in which the general practitioner finds himself, and will continue to find him¬
self, in need of expert advice, and that he will not commonly take the sole
responsibility of deciding how the patient should be disposed of. I think a special
case can be made out for an arrangement under the general scheme, with the
agreement of the controlling authorities of mental hospitals and psychiatric
clinics, whereby a reasonable fee is payable to the staff of these institutions for

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NOTES AND NEWS.

[Oct.,

this consultative work out of local or State funds, in cases where the patient has
no means. In suitable cases, and where distance allows, the patient can be sent
by his doctor to the out-patient department of the nearest psychiatric clinic, or of
the nearest mental hospital, should such department exist at the latter, and advice
as to his disposal be thus obtained. However obtained, expert advise could
decide whether the patient should be dealt with in hospital under (£), (c) or ( d ) ;
whether—exceptionally—by reason of the gravity of his symptoms, nothwith-
standing their recent origin, or of insufficient accommodation being available
under ( d ), the case should go to a mental hospital. When the case falls to be
treated under (A), his own doctor should look after him, whenever possible,
expert advice being available. Under (c) the patient will be under the care of a
member of the visiting staff. Expert advice in this instance will, for a time, only
be available from the mental hospital and psychiatric clinic, the senior staff being
placed on the visiting staff of the hospital. But these clinics will in time furnish
specialists for the large towns, who will be on the staffs of the hospitals with
psychiatric wards. The consulting work of the district would be done by the
director of the clinic and by these specialists. As consulting work is an essential
part of the recommendations of the Interim Report, the need for clinics in
psychiatry, in this instance for the training of consultants, is once more
emphasised.

It is highly desirable that patients who are convalescent from the maladies here
dealt with—and no doubt the same is true of most diseases—should not return
direct to their homes, but through a convalescent home or sanatorium. Recupera¬
tive centres are, I observe, recommended (para. 74) in the Interim Report.

If the psychoses are to be dealt with under a three-hospital system a modification
of the Lunacy Laws will be necessary, and therefore the recent presentation in the
House of Commons of the Ministry of Health (Miscellaneous Provisions) Bill,
which authorises under Clause 10 the care and treatment of cases of mental disorder
" incipient in character and recent in origin,” notwithstanding the provisions of any
existing Act, is welcome. I observe nothing in the proposals of the Minister of
Health which would render impracticable the scheme of care and treatment herein
outlined, though the observance of certain formalities, such as the notification of
reception, the production on authorised demand of written consents and certificates,
is likely to prove irksome and to cause resentment at the outset. No vivid
imagination is needed to forecast the administration hereafter, in whole or in
part, of a three-hospital system, under Clause 11 of the Bill, by local authorities.
These should meantime be diligently advised to insist on provision under any
such system for cases of the psychoses and psychoneuroses.— Vide Lancet ,
September nth, 1920.

DIPLOMAS IN PSYCHOLOGICAL MEDICINE.

The needs for schools of psychiatry were well stated two years ago in the
annual report of the Board of Control, when attention was called to deficiencies in
the arrangements as at present organised for the treatment of persons suffering
from mental 1 disorder, especially in its early stages. During the two years that
have elapsed both the loss to the country and the hardship to individuals resulting
from insufficient attention to incipient mental cases have been recognised by the
medical profession and all sections of the thinking public, so that any educational
development improving the scientific position of psychological medicine will meet
with warm approval.

Diplomas in psychological medicine, though of comparatively recent date, have
been instituted at various centres for some ten years, while affiliation of mental
clinics to the teaching in general hospitals has been much recommended. When
this takes places there will be no dearth of suitable applicants for posts at asylums,
for many young men can then be trained to take up the work in sympathetic
and scientific spirit. But before the lunacy service can become attractive, the
views of the Board of Control, which have been stated to the visiting committees
of asylums, must receive practical expression by a general improvement in salaries,
in accommodation for married officers, and by the provision in asylums for the
more effective treatment upon modern lines of recoverable cases. The following
bodies have now arranged to grant diplomas in psychological medicine or

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psychiatry, namely, the Universities of Manchester, Leeds, Edinburgh, Cambridge,
Durham, and London, and the Royal College of Physicians of London. The
regulations for obtaining these diplomas point to much similarity in the scope of
the examinations, though there are differences in the duration of the courses and
the syllabus, details of which can be obtained from the various examining bodies.

The necessity for raising the standard of the training for assistant medical
officers in asylums, and of affording facilities for such training, is very real. If
the authorities give proper preference to the candidates for vacancies who possess
diplomas or degrees in mental disease the status of this branch of the medical
profession will be automatically raised, and pay and conditions of service will have
to be made commensurate. It is necessary that the authorities should make
arrangements to grant study-leave on full pay to their Assistant Medical Officers,
especially if it is the object of these officers to obtain a diploma which they were
previously without; and augmented salary might well be paid to successful
examinees. In the face of the facts acquired in recent years as to mental health,
it is necessary that psychological medicine should now form an integral if special
part of medical education, so that no University should willingly be without
such an organic unit as a school of psychiatry.— Lancet, August 28th, 1920.

The study of mental diseases has long been a necessary part of the ordinary
medical curriculum, and psychiatry is one of the branches of medicine which
candidates for the M.D. degree of the Universities of London and Edinburgh can
take up. In addition, diplomas in psychiatry or psychological medicine can be
obtained from the Universities of Cambridge, London, Edinburgh, Durham,
Leeds, Manchester, and the National University of Ireland, and from the Royal
College of Physicians of London. The Medico-Psychological Association of Great
Britain and Ireland also grants certificates of proficiency after examination, and en¬
courages the study of psychiatry by the offer of prizes for original and research work.

Those who take up psychiatry as a career work as medical officers of public or
private mental hospitals, or similar institutions. In practically all cases they are
resident officers, having board, lodging, etc., either in the hospital itself or a
residence in the grounds. Junior assistant medical officers receive about £300
per annum and senior assistant medical officers about £500, in both cases with
board, lodging, laundry, etc., in addition ; if married the value of board, etc., is
commuted for cash. Medical superintendents, whose pay commonly ranges
between £800 and .£1,500 per annum, are provided with a house in the grounds
of the hospital and draw various allowances.

Since the passing of the Asylum Officers' Superannuation Act in 1909, all
officers and others of the established staff of a mental hospital may retire at the
age of 55 on a pension varying from one-half to two-thirds of the value of their
pay and emoluments, or one-fiftieth for every year served, paying as contribution
3 per cent, of the value of their appointments annually. This very favourable
prospect may not appeal to juniors joining the services, but is an eventually
valuable asset.

Mental hospital work has undoubtedly not been in favour with newly-qualified
medical men in years past, the principal reasons alleged for this being as follows :
(1) It is a local and, except indirectly, not an imperial service; this tends to slow
and uncertain promotion. (2) The rule or custom hitherto prevailing, that
assistant medical officers may not marry and are merely perpetual house-surgeons,
living as bachelors in rooms. (3) That much of their work is clerical, administra¬
tive and routine, which, if not destructive to the medically trained individual, is at
least not conducive to scientific medical initiative, as in medical service in the
army or other public services, rather than the possibly more attractive general
hospital, or private practice, work.

In March, 1920, the Board of Control did useful service by issuing to visiting
committees of asylums a circular upon the three following matters: (a) The
dearth of suitable applicants when vacancies occur for the post of assistant
medical officer, and the probable causes thereof; (6) the need for the provision
for the more effective treatment upon modern lines of recoverable cases of mental
disorder; (c) the necessity for raising the standard as to the training of existing
and future assistant medical officers in asylum practice, and of affording facilities
for such training.

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Under (a) the Board of Control, after pointing out some of the disadvantages
of the present state of affairs, made the following suggestions:

(i) That an improvement be made in the salaries of the assistant medical
officers, at least to such an extent that in the cases of all those who have been in
the service above a certain number of years and are regarded as permanent
officials, the salary should be reasonably sufficient for a married medical man, and
that in the case of the deputy superintendent it should more closely approximate
than at present to that of the superintendent.

(ii) That, in the case of a permanent official, application for permission to marry
be not required ; that, according to circumstances, proper accommodation for a
married man be provided, and that, subject to rules approved by the Secretary of
State for the protection of the patients, and with due regard to the proper
administration of the institution, permission to live out may be granted.

(iii) That to the title of assistant medical officer the words “ and deputy
superintendent ” should be added to that of the one selected to be in charge during
the absence of the medical superintendent.

(iv) That the use of the title “ senior assistant medical officer ” should not be
restricted as at present to the post of first assistant, but should be extended and be
indicative of a certain standing and expert knowledge. By the adoption of this
suggestion there would in many asylums be two senior assistant medical officers,
and perhaps even three or four in the largest asylums.

(v) That, except where there has been previous asylum experience, appointments
to posts of assistant medical officers should in the first instance be temporary in
character.

Under (6) the Board suggested that the treatment of recent recoverable cases
should be carried out by members of the medical staff conversant with modern
methods, and that the number of the medical staff should be sufficient to ensure
that none of them is required to undertake the treatment of more than fifty recent
cases at any one time.

Under (c) suggestions were made with a view to encouraging assistant medical
officers to obtain a diploma or degree in mental diseases, including provision for
study-leave on full salary. The attitude of the Board of Control is clearly shown
in the following sentence : “ If the welfare, treatment and recovery of patients is
not to be jeopardised and the study of mental diseases is not to lag behind the
study of other branches of medicine, the Board feel the necessity of initiating
measures to maintain progress and to secure the best possible treatment of the
patients.” Readers who wish to go further into this subject may be referred to an
interesting paper(‘) read before the Medico-Psychological Association in November,
1919, by Dr. C. Hubert Bond, on the need for schools of psychiatry. In this Dr.
Bond urges the need for mental clinics and schools of psychiatry, and reviews the
progress that has been made towards realising the measures, powerfully advocated
in 1908 by Lieut.-Col. D. G. Thomson, for supplying adequate instruction in the
institutes and practice of psychiatry.

Both the British Medical Association and the Medico-Psychological Association
are working separately and together to improve present conditions of service, and
have, for example, already removed the “ celibacy” objection to the service.

Finally, it may be said that, as in the Army Medical Service or other public
medical services, while routine, administrative and clerical work bulk largely in
mental hospital duties, there is ample material, time and scope for purely medical
work, difficult as the subject may be, in psychiatry as one of the branches of
medicine open to young graduates.— Vide Brit. Med. Jonrn., September 4th, 1920.

(') Journ. Ment. Sci., January, 1920.

EDUCATIONAL NOTES.

Maudsley Hospital .—It has been decided to repeat Part I of the course for
a diploma of psychological medicine and to run it concurrently with Part II during
October, November and December—in other words to commence the Second
Course 1920-21 this October. The syllabus published on p. 194 (April number)
remains the same, except that as regards Part I the lectures are reduced to eight in

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number and Dr. Henry Devine replaces Dr. J. V. Lowson as the Lecturer on
Psychology ; and as regards Part II courses 5 and 6 are withdrawn. Part II of the
Second Course will follow in January, 1921, a further announcement regarding
which will be made in due course. Inquiries as to lectures, etc., should be
addressed to "The Director of the Pathological Laboratory, Maudsley Hospital,
Denmark Hill, S.E.”

University of London. —We have received from the Registrar of the University
Extension Board a copy of the regulations for obtaining the recently instituted
diploma in psychological medicine. The examination is in two parts—A and B—
the former in March and October, the latter in April and November. Candidates
must be on the Medical Register, and before admission to Part B must have held
for not less than six months a resident appointment at an institution for mental
diseases recognised for the purpose, or have attended for not less than twelve
months the practice of such an institution. Part A comprises a paper and a
practical examination in the anatomy, histology and physiology of the nervous
system and of a paper and an oral examination in psychology.

Part B comprises a paper, a clinical and an oral examination in neurology, and
two papers, a clinical and an oral examination in psychological medicine. As
regards the papers there will be alternative sections to enable the candidate to show
either a higher knowledge of mental disease and a less advanced knowledge of
mental deficiency or vice versd.

The examinations commence for the first in October and November. For further
information application should be made to John Lea, Esq., M.A., University
Extension Registrar, University of London, South Kensington, S.W. 7.

OBITUARY.

Dr. John Batty Tuke.

Superintendent, New Saughton Hall, Midlothian.

The elder surviving son of the illustrious Sir John Batty Tuke passed away on
April nth at a nursing home in London. Dr. John Batty Tuke was born in i860,
and after passing through the Edinburgh Academy, where his father before him
was educated, graduated M.B., C.M. Edinburgh University in 1881, and took the
degree of M.D. in 1890. In 1887 he became a Member of the Royal College of
Physicians, Edinburgh, and was raised to the Fellowship in 1889. As might have
been expected, he followed in his father’s footsteps and selected psychiatry as his
life’s work. He first acted as Assistant Medical Officer to the Royal Asylum,
Montrose, and then as Resident Clinical Assistant at Wakefield Asylum, a post which
has been held by many of the foremost members of our specialty. Later he joined
his father in the management of Saughton Hall and later of New Saughton Hall,
and finally succeeded him as Medical Superintendent of the latter hospital in 1913.
He had also a consulting practice, and was Physician for Mental Diseases to the
New Town Dispensary, Edinburgh. Although overshadowed by his father’s unique
personality and great reputation, he was a gifted alienist, a thoughtful and
painstaking physician, and had many friends who will miss him much. His
publications were few, but the proposal made in 1913 that confinement in an
asylum for five years should be a ground for divorce roused his considerable
opposition. He pointed out that many patients recovered long after that period
had elapsed, instancing a case under his care which recovered completely after an
attack lasting seventeen years. He maintained that the opportunity for child¬
bearing enjoyed by women who are in and out of asylums owing to the occurrence
of short attacks of mental trouble, say, connected with the puerperium was more
likely to assist race deterioration than in the cases of women not infrequently set
at liberty after five years’ or more detention. If insanity was to be a ground for
divorce, then why not tuberculosis? he asked. However, Tuke (junior) was
essentially a quiet, unassuming man, who did his day’s duty silently and well and
was not by nature a controversialist. Latterly he was known to be suffering from
a serious disease, but the end came unexpectedly early.

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NOTES AND NEWS.

[Oct.,

NOTICES BY THE REGISTRAR.

Nursing Certificate. —The next examinations will be held as follows :

Preliminary.November 1st, 1920.

Final.November 8th, 1920.

Examination for the Certificate in Psychological Medicine,

July 6th, 1920.

1. Describe the histological changes in general paralysis of the insane.

2. Give a clinical account of a case of paranoia.

3. Detail the treatment in a case of senile insanity.

4. Discuss the differential diagnosis between general paralysis and arterio¬
sclerotic brain disease from the point of view of mental, physical and serological
findings.

5. State briefly some of the psycho-analytic theories. Give examples of some
of the more common complexes.

6. Write a note on “ alternating insanity.” What is the prognosis in such a
condition ?

Successful Candidate: Dr. J. N. Russell, of Wakefield.

Examination for the Nursing Certificate, May, 1920.

Preliminary Examinations.

1. Describe fully the respiratory system and the blood changes that take place
as a result of respiration.

2. What are the symptoms of a patient who has taken a corrosive poison, and
what treatment must be adopted by the nurse ?

3. How is meat digested, and how is the resulting peptone finally absorbed into
the blood ?

4. What are the different kinds of joints? Name the bones which go to make
up the elbow-joint, hip-joint, knee-joint.

5. Describe the emergency treatment you would adopt in a case of shock
following a severe injury.

6. State the position in the body of the following organs : Liver, spleen, pancreas,
kidneys, heart.

7. How is the pulse produced? Where is it best felt? What is the pulse-rate
and how is it related to the heart-beat ?

8. What first-aid treatment would you render for a sprained.ankle ?

Final Examination.

1. State exactly the steps you would take to control haemorrhage in the case of
(1) a ruptured varicose vein, (2) bleeding from the nose, (3) a severe wound on the
front of the arm.

2. Describe fully all the causes you know of which may produce refusal of food
in a patient.

3. State in detail how you would endeavour to interest and employ your patients
on a wet day when they were unable to be out of doors.

4. Describe and compare (1) an hysterical fit, (2) an epileptic fit, (3) a seizure in
general paralysis of the insane, (4) an apoplectic seizure. What are the nurse's
duties in each case ?

5. What urinary troubles are common among insane patients ? What points
should the nurse observe and report to the Medical Officer regarding a patient's
urine ?

6. What would lead you to suspect suicidal tendencies in a patient ? What
must a nurse do to avoid the risk of suicide in the case of any patient under her
care ?

7. State the cause of phthisis or consumption. Describe the ordinary symptoms,
and the precautions necessary in nursing.

8. What is (n) a motor nerve, (6) a sensory nerve, and what are their functions ?

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1920.] NOTES AND NEWS. 509

Nursing Examination for Candidates in Mental Deficiency Work,

May, 1920.

Final Examination.

1. Describe briefly the organs of respiration and their functions in health, and
state the more common forms of respiratory disease, mentioning the signs and
symptoms of those to which mentally deficient children are particularly prone.

2. Name some of the physical peculiarities and the affections of sense-organs
frequently found associated with mental defect. What do you understand by the
expression "stigmata of degeneration" ?

3. What do you regard as the distinctive difference between cases classed as
insane and those dealt with as mentally defective under the Mental Deficiency
Act, 1913? How are the latter classified under that Act?

4. Mention the more striking varieties of type observed amongst mental defec¬
tives, and describe the characteristics, physical and mental, of the microcephalic
type.

5. What points would you specially note on the admission to an institution for
defectives of a patient entrusted to your care ?

6. What sign would lead you to suspect that a child under your charge was
sickening for measles ? Give an account of the usual course of the disease, of
possible complications, and of nursing precautions to be adopted.

7. Give some account of methods of manual and physical training and of
industrial occupation found serviceable in institutions for defectives.

8. State what bad habits have specially to be guarded against in the case of
mental defectives, and what measures you would take to check evil practices.

Preliminary Examination, May, 1920.

List of Successful Candidates.

Three Counties, Hilchen. —Florence Brown.

Berkshire. —Wiliiam Fry, Simeon J. Scard, W. H. Melbourne, Harriett Kirk,
Grace M. Kirk.

Carnbs, Fulbourne. —A. F. Wilkins, Jessie W. Cornell, Charles Holder, Verney
Hodgman, Albert F. Minett, Kate Pickstone, Ellen A. Thurston, Rose P. Deacon.

Chester County. —Nesta C. Morris, Ellen Bungay, Anne Williams, Alice E.
Edwards, Annie Riley, Henry T. Bromley, Joseph Ellis, John Jenkinson, Thomas
Whalley, Harold Titley, John F. Pottle.

Macclesfield. —Thomas Coppock, Ernest Young, Harry Bannister, Catherine
Thompson, Mary Pearson, Gladys Belcher

Cumberland. —Annie Boyce, May Allison, Charlotte Foster, Jean Bain.

Cornwall, Bodmin. —Arthur J. Wendon, Isaac Tiller, Alfred J. Stevens, A. R.
Weller, Thomas Roskelly, Frederick E. Wadge, George Hearn, Charles J. Gill,
John T. Pearce, Richard W. Bunny, J. H. Battershill, Thomas H. Bligh, Arthur
[. Taper, John H. Stephens, Ernest Hamley, Beatrice M. Veale, Gladys May
Wilce, Beatrice A. Bennetto, Emily T. Hamley, Lucinda Mitchell, Charles Henry
Pomery.

Denbigh. —John Evans, Richard Blythen, Robert Roberts.

Derby County. —Frank Partington, William H. Hammond, Margaret Murphy.

Devon County. — Lilian E. Warner, Jessie Barrell, Ethel F. Gunn, Alice Osmant,
William Trenchard, Joseph Wm. Kevern.

Dorset County. —Stanley Whetham, Alice M. Cross, Phyllis W. Osmand, Ethel
May Carter, George Paul, T. B. P. Dunman, Dorothy E. Dunn, Louisa Dore,
Mary Jane Lowman, P. E. Winter, Dorothy M. James, Catherine E. Adams,
Evelyn M. Pitcher, Ernest F. Woolford, F. J. Christopher, Ivy Emma Allen, Shelia
C. Kelly, Greta K. Sheppard.

Durham County. —F. A. E. Thompson, Ernest William Davis, James R. Bentley,
James McPhee, Thomas Cowley, Ernest Scott, Frank C. Alton, John R. Holmes,
jean Thomson, Eva G. Stanley, Agnes Wigham, Florence Bradley, Mahalah E.
Dyer, Maggie Keegan, Mary H. Allison, Sarah Dykes Arkle, Emily Thompson,
Ada Clark, Rachel Thomas.

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5 io

NOTES AND NEWS.

[Oct.,

Essex, Severalls. — Margaret A. Collyer, Gladys E. Davies, Alice B. Dawson,
Ivy Gardner, Dorothy Dunning, Ellen D. Gillings, Margaret L. Hicks, Violet loll}’,
Elizabeth Kinimonth, Lily L. Leatherdale, Mary L. Loveday, C. Macfarlane, Jessie
Macfarlane, Mary Mullen, Doris M. Noble, H. M. G. Palk, Gwendoline D. Price,
Eveline Parker, Dorothy M. Smith, Dora Spurgeon, Sarah M. F. Still, Gertrude
Sykes, Rosalind A. V. Webb, A. Oliver Sage, Leonard William Smith, Walter
Melhuish, William Bailey Holmes, Frederick J. Taylor, William H. Swaine,
Frederick Stirling, Charles Moore, Robert C. Wainwright, George L. Norville,
Robert Bessey, William Newnham, Frederick J. Kingswell, William Orme, George
H. Readman, George F. Turner, William Ready, George Henry Flatt, Albert Ed.
Dixon, Thomas William Deas, George M. Hockley, J. W. Hudd.

Brentwood. — Margaret Thomas, Ethel Hare, Florence D. Double, Elsie A. E.
Mudd, Emmeline B. Wilmott, Mary Kew, Eleanor Greenfield, Ivy Moat, Annie
Whitehead, Henry John Richardson, George Laundy, John Victor Cressey.

Hill End, St. Albans. —William Huggett, James Charles Day, James H.
Graham, Percy Phillips, Frances M. Clifton, Emily Weller, Rose Westwood.

Glamorgan. —Elsie Richards, Elizabeth Daley, Lizzie Roberts, Mary E. Thomas,
Clifford Ings, Mary Davies, Edwin T. Williams, John Tudgey, Mary E. Phillips,
David J. Morgan, Alice Gawthrop, Doris Crocombe, Florence A. Belsham,
Margaret Vile.

Isle of Wight.— Beatrice Allen, Evelyn Allerton, Lily Beauchamp, Irene Choate,
Kathleen M. Hayes, Charles E. Brown, Frank H. Griffin.

Banning Heath. —Stanley F. Adams, George W. Goldsmith, John Henry
Harris, William Humphrey, Fred Lambeth, Percy T. Pronger, Victor Startup,
Richard Thompson, William J. Wallis, Arthur J. Woollett, Dorothy M. Honeysett,
Mary Jane Jones, Millie Killian, Bertha Rees, Beatrix Julia Wall, Anthony F.
Flynn.

Chartham. — Louie M. A. Foord, Frederick G. Gould, Harold E. George,
Sidney H. Stockbridge, Elsie Field, Henry E. Weatherall.

City of London. —Bessie Brown, William T. Robinson.

Bracebridge, Lines. —George W. Hough, George Baumber, William Wilson,
George A. Moss, George Wilson, Thomas Straw, William Brackenbury, Arthur
Bott, Frank Weldon, Harry Wright, Herbert Norton, Eliza Rhodes, Louisa
Would, Lucy M. Mannifield, Elsie Spooner, Caroline Hawks, Ivy Elizabeth Blow,
Jessie Simpson, Harriett Holmes, Ada L. Cooper, Amelia White, Alicia Kendall,
Florence Si. Chambers, Edith Freeman, Edith Bristow, Alice Ogden, Dorothy
Jelley.

Kesteven. —George Brumpton, Charles S. Boddy, John Taylor, Ambrose C.
Smith, Lilly Harris, Fanny Bainbridge.

L.C.C., Bexley. —Annie Reilly, Lily Maddcock, Lucy M. Gillard, DorothyJMc-
Entegart, Phyllis E. Knell, Dexter T. Skevington, Frederick L. Partridge, Edwin J.
Waller, Sam M. Hodgson, Richard N. Lunn, Arthur G. Draycott, Arthur S. Riches,
Archibald Russell, Frederick C. Thomson, Albert A. Fackerell, Leo George
Knight, Alfred R. Linford, Alfred E. Mummery, John P. McAloon, Frederick
George Bates, James T. Williams, Ernest C. Jeeves, Ernest William Smith,
Walter E. Yates, Henry W. Tarrant, Frank S. Allen, Frederick H. Thorpe,
Harry H. Ryder, Walter B. Palmer, John P. Carron, Mary Tresnan, Margaret W.
Flockhart, Bessie Holloway, Nancy Galvin, Delia McHugh, Mollie Fitzpatrick,
Matilda Breslin, Dorie E. C. Gowthorpe, Winifred E. Sly, Alice M. S. Collins,
F. A. Parncutt, Hettie E. Jolley, Pauline Watson, Julia Barry, Hilda Emily
Hendrick, Ellen M. Zallberg, Lily Owen, Laura E. Bloomfield, Hilda W. Pepper,
Katherine S. Travnor, Winifred M. Allsopp, Florence Shaw, Eliza Esther Ewers,
Rose L. E. Cook, Lily Mary Jones, Ida Bennett, Mabel E. Newton, Annie Macey,
Bridget Dowling, Frances C. Jones, Florence E. Banks.

L.C.C., Ewell. —James A. Clark, Arthur J. Herbert, Alex. MacLennan, Michael J.
Reardon, Sidney Simmons, Edward J. Bridgman.

L.C.C., Cane Hill. —Charles E. Wheeler, Arthur Brackenbury, Frank E.Buckland,
George J. Norman, Percival B. Randall, Herbert H. Sayer, Amy E. Gilbert,
Beatrice Londwell, Charlotte Randall, May Ellis, Sarah Ann Taylor, Florrie
Myland, Violet May Westover, Emily Toogood, Gertrude Campbell, Eliza J. Fife,
Violet Annie Cummings, Annie E. Cronin, May Ethel Bryson, Bertha May Jones,
Edith Palmer, Susan Brewster, Lilian Daisy Revell, Johanna Donovan, Gertrude

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1920.]

NOTES AND NEWS.

5 11

E. Smith, Lyna Nicholson, Amy Janet Smith, Margaret Deeves, Linda B. L.
Barton, Mabel Setter, Louise M. Hibling.

L.C.C., Colney Hatch. —Mary A. M. Hunter, Jennie A. O'Callaghan, Ina Marie
Holder, Evelyn Rose Vince, Walter J. Hutchings, Charles Alfred Bye, Edgar John
Hart, Barry James Digweed, Horace E. Paine, Henry Church, Alexander Eddie,
Harry S. Diddams, William Cooper, Harold F. Barnes, Walter Robinson, Charles
W. Fairbairn.

L.C.C., Hartwell. —Mary E. Fravier, Elizabeth D. Ponter, Katherine Gellard,
Ceinwen Jones, Katherine L. Chew, Alice E. Weeks, Edith Martin, Ellen Payne,
Margaret Dingle, Ellen A. Naughton, Olive Mary Faulks, Grace Evelyn Dear, Elsie
M. Phillipson, Elizabeth Croft, Alice Maud Marke, Elsie M. Maynard, Gertrude A.
Leonard, Lilian Kay, Frederick William Hillbert, Frederick Mant, Thomas Danby,
Benjamin Springle, Alexander Clapperton, John E. Ayres, William Edwin
Turrell, Arthur B. Clarke, Alfred James Bowden, George H. Bint, Ernest J.
Newton, Thomas A. E. Marshall, Frederick Reeve, Harry E. Williams, Herbert
Murrell, William Onyett, Sydney Frank Meadows.

L.C.C., Horton. —Harry Chandler, Walter J. Blunden, Herbert Stockman, Oscar
H. Smith, Robert S. Spong, Harry Wheeler, Henry T. W. Appleby, Albert V.
Knight, William Lipscombe, William A. Soole, William J. Oliver, William G.
Cotterell, James John Sibley, George R. Stevens, George Stevenson, Sidney J.
Farley, Alfred Lancley, Eleanor Hughes, Henrietta Pinchin, Mary Dillon, Jennie
Amos, Florence Hilda Hughes, Lilian G. Jordan, Harriett Clark, Mabel Edith
Buck, Jeanette Buck, Florence Ellen Merritt, Bridget L. Carolan, Mary L. Wadkin.

L.C.C., Long Grove. —Henrietta Thomas, Martha Ann Wilson, Kathleen M.
Holden, Carrie L. Dobinson, Ann Jane Blatchford, Louisa Law, Selina E. Andric,
Annie M. Markham, Herbert Rymills, George Edward Cooper, Frederick Brown,
Arthur Shrimpton, Benjamin Chapman, Sidney P. Wetherill, Richard Smith,
Joseph A. Moran, William Garton, Alfred H. Durbridge.

L.C.C., Manor. —Ronald A. Partrick, John Keary, Albert Arthur Catlin, Stephen
John Webb, Wilfred J. Connett, Jennie Russell, Beatrice M. Bowen, Florence G.
Marshall, Teresa King, Florence Annie Loinas, Mary Alice Travers, Harriett
Curling, Eliza J. Williams, Hilda Julia Moore, Florence Keeble, Helena J. Travers,
Nellie Boseley, Hilda M. A. Miller, Elsie G. Pulford, Dorothy Christie, Violet
Eveline Wood, Lilian Carter, Kathleen Burke, Hannah E. Hulme, Beatrice Cox,
Adelaide Byrne, Edward C. Tolley.

Springfield, Middlesex. —Frederick C. Kennedy, William A. Rogers, Barbara
Preston, Victoria Varney, Edith Wyatt, Fanny H. Coggan, Hilda Kate Picknell,
Lilian Spray, Margaret Meaney, Mary J. Thistleton, Margaret McCann, Frances
Harris, Kathleen E. A. Hubbard, Lucie Southwell, Albert E. Clifton, Walter
Henry Allen, Edgar Paterson, Ernest Walker, Francis G. Reardon, Frederick G.
Richards, Frederick J. Morgan, George A. Hoare.

Napsbury. —Lucy Logan, Charlotte Connor, Gladys May Milsom, Elsie E.
Lovering, Jennie Whitehead, Bertha Rose Garrod, Elizabeth A. Hagon, Ernest
Maybank, Annie Rose, Albert Edward Collyer, Alfred Prideaux, Ellen Leonard,
George McKeag, Frederick George Ribbens, William Henry Rose, John J.
Costello.

Norfolk County. —Martha Honsley, Winifred A. Foulsham, Mary E. Howard,
Ethel Violet Lee, Ellen Hill, Ivy May Rudd, Fanny Heyes, Lily Lowe, Winifred E.
Heugh.

Newport, Mon. —Jesse A. Davis, Henry Perkins, John Riordan, Philip E. Waller,
Ada Coombs, Martha E. Lewis, Dorothy M. Wilson, Lucy Pitt Brown, Florence
A. Tucker, Adelaide M. Williams, Edith Maddocks, Margaret A. Raines.

Berrywood. —Nelly Jones, Rose Higham, Lilian Sedman, Frederick G. Harrison,
John Lawton, George W. Rudkin, Norman Whitlock.

Notts County. —Sarah Griffiths, Alfred L. Todd, Mabel Nicholls, Wilfred
Bamforth.

Northumberland, Morpeth. —Eleanor Stacey, Margaret Owens, Margaret Finney,
Jane Pringle, Ernest Moffatt, Bertram Gosling, Harold G. Callaghan, George
Price, Mark H. Arnott, William Gibson Hodgson, Reginald A. Tyson, William
H. Sanderson, William T. Proudlock, Charles McGregor, James Hall, John
William Pearson, Violet Finlay, Edith Moore, Dorothy Johnson, Charlotte Massey,
Dora Ruecroft, George Hall.

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512 NOTES AND NEWS. [Oct.,

Shrewsbury. —Alice May Jones, Elsie Mary Haycocks, Doris May Pritchard,
Marie Hughes, Dorothy May Mills, Mary Ellen Jones.

Cheddleton. —Helen M. Burgess, Alice K. M. Gilbert, Arthur J. Knight.

Stafford. —George Barker, Frank A. Davies, Frederick J. Dodd, Arthur Lewis,
Arthur Sammons, Millie Gerrard.

Burntwood. —Joseph Garner, David William Plumb, Henry Powell, John C.
Jones, Violet C. Stockton, George Guise.

Brockwood. —William T. Capon, Frederick J. B. Grenham, John Kent, John
Carter, William C. Roberts, Thomas W. Willoughby, William H. Arthur, Herbert
William Rapley, Herbert Coleman, Ruby F. Curtis, Minnie Hammond, Daisy J.
Smith, Daisy Curtis, Marjorie Winifred Hicks, Lottie Berry, Laura Agnes
Gooderham, Ava A. Chandler, Lilian Mary Cove, Hilda A. Toogood, Lucie K.
Long, Margaret Brett, Ada E. Seymour, Nellie Warren, Mary McLeod.

Netherne. —Millie K. Le Lievre, Alice Kelley, Elsie F. Dodd, Annie Morris,
Elizabeth Mills, Marjorie Midwinter, Mary Arthur, Charlotte Nicholls, Margaret
Quinlan, Dora Michelmas, Florence Roberts, John T. Little, G. A. E. Bartlett,
Herbert C. Rowland, Sydney H. Toogood, Harry C. Voller, William H. Evison.

Hellingly. —Nellie D. Hughes, Mary V. Blake, Hugh T. Clifford, Stanley E.
Masters, Herbert J. Medhurst, Stanley G. Betts, Alice Marvel, George H. Townsend.

West Sussex. —Mary P. George, Bertha Mitchell, Lily V. Russell, Kathleen
Scanlan, Florence May Smith.

Beverley. —Samuel Dove, Sarah Elizabeth Mant, Sarah E. Akrill, Doris K.
Butler, Harry Crowe, Alice Wiffin, Eva Oxtoby, Margaret Walshe, William
Slator, Thomas Anthony, Maud W. Chambers, Muriel N.Cressey.

Bromsgrove, Barnsley Hall. —David S. Creasey, Frank P. Seaman, Thomas
Smith, Amy G. Barnett.

Scalebor Park. —Katherine Wishart, Margaret Wilson, Emily Richardson, Ellen
Lee, Margaret Ellis, Gladys Oakley, Annie Mordue, Edith Watson.

Storthes Hall. —Eveline Gomersall, Nellie Beatrice Cooper, Olive Cunnington.

North Riding. —Arthur Turner, Walter Spence, Florence Morgan, Bridie Burke.

Winson Green. —Clara E. Bullivant, Alice Bullock.

Haywards Heath. —Percy G. Raife, George Bridger, William Davey, Mabel
Clifford, Ethel Croxford, Lilian Webb, Walter French, Mary E. English, Wini¬
fred M. Read, Annie Barrett, Ethel Fox, George Bedchamber, Albert E. Fleckner,
Robert J. Martin, Edgar S. Mullins, Ada Hodgetts, Lily Inwood.

Bristol City. —Florence May Sollars, Edward G. Roach, William J. Vardy.

Canterbury. —Linda V. Mildenhall, Sabina S. Mildenhall, Lilian B. Honey,
Ernest W. Harris.

Derby Borough. —Florence Frost, Annie Naylor, Ida Mary Wilkinson, Thomas
Boole, Richard T. Chater, Joe Leigh.

Exeter. —Edwin W. Lane, John William B. Wills, Charles F. Crook, Alice
Blanche Wood, William Woolf, Henry S. Henderson.

Gateshead. —Victor S. Dodds, Francis William Henry.

Hull City. —John Ellison, Mabel Cook, Gladys Edith Neal, Alice C. Scholes,
Hilda Watson.

Leicester Borough. —William C. Hernon, Timothy G. Elliott, Margaret Kenna,
Marjorie Winfield, May I. B. Litchfield, Rose E. Clarke, Mary J. Byrne, Doris
Ward.

Notts City. —William Briggs, George Percy Barrow, Willie A. Ryan, Emily
Grange, Edith A. Chambers, Mary M. Rose, Dorothy May Hill, Annie L. Bradbury,
Bridget Casey.

York City. —Leonard Knight, Annie McKeen, Elizabeth Pickering, Elsie Poynton.

Plymouth. —Gladys Maud Angear, Vera Mabel Bounds, Marie Adelaide Moore,
Ivy H. W. Tedder, Rhoda May Wyatt, Claude Bartlett, Ernest Brooking, Bertie
Ernest Camp, John H. Moore, Edwin H. Ryder, Arthur Worth.

Portsmouth. —Edith Mary Lillington, Gladys I. M. Stretton, Gladys A. Brownie,
Eva Maud Pitt, Josephine McGrath, Ivy Barnes, Mabel White, Emily Williams,
Albert F. Southwell, William E. Williams, Percivai Lance, Charles Hurlings,
George Read, Robert E. Jerram, John Henry Swan.

Sunderland. —Andrew McGreever, Thomas McNulty, Thomas G. Minto,
Thomas Mulleney, James Page, Thomas Richardson, Samuel Smith, Thomas
Young, May Cowley, Hannah Bell Crawford, Charles Edward Haynes.

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1920.]

NOTES AND NEWS.

513

Tooting Dec. —Maria Walker, Maud Mayhew, Eva A. Rogers, Phoebe Waugh,
Martha Ann Evans, Doris Marmont, Florence M. Townson, Elsie E. Williams,
Frederick G. Cable, Frederick Ford, Charles Hope, Arthur Price, Thomas Higgins,
|ames Newsom, William Richards, Sydney T. Hubbard, Walter T. Mortley,
William Robert Humphries, Frederick Shelley, Rodney W. Morris, Eric Robert
Moss, John Gahagan, William A. Crouch, George L. Hammond, Arthur Taylor,
Hermann T. B. Brewer, Alfred G. Barkham, Thomas Barrett.

Leavesden. —Thomas H. H. Simmons, John Labram, Reginald E. Williams,
William G. McLean, Hubert Brown, Grace B. Pearce, Annie Harding, Elsie G.
Gridley, Jane E. Higginson, Nellie Howard, Dorothy R. Scott, Margaret H.
Wellstead, Maud F. Ware, Olive Miller, Horace G. Hill, William H. Chandler,
Joseph Turnbull, Frederick John Hudson, George Rowe, Charles Brittain, Arthur
J. Palmer, George William Davis, John H. Chappie, Edwin J. Miller, John J.
Narroway, George Ed. Taylor, Horace J. Kempster, Frederick H. Horsnell,
Harry Hardwick, William Billing, Percy Lawrence, Frank N. Bradford, Harry
Tilby, Herbert Dade, Donald King, Frederick Davison, Edwin B. Jackson, George
Melton, Flora Bennett, Minnie Patterson, Elizabeth M. Kelsey, May Jones, Elsie
R. Stead, Annie Beasley, Amilie R. A. Hill, Emily M. Moore, May Jarrett, Elsie
M. Cooper.

Darenth. —Sarah K. Joyce, Myrtle L. Willmott, Amy Thorpe, Rose E. Gallon,
Ethel M. Easton, Ellen E. Simpkin, Florence Simpkin, Phoebe Kcmpton, Annie
D. Thorne, Annie Burks, Agnes M. Brigden, Elizabeth Addison, Nellie A. Ridway,
Helen L. Ackland, Winifred M. Palmer, Rose M. Tipper, Sarah A. Farrance, Ella
Coughlan, George F. D. Crook, Francis W. Jackson, james R. Draper, Walter H.
Connor, E. Charles Walker, William J. Butler, Frederick W. Fairbrass, Edmund
Kinchin.

Caterham. —Alfred William Thorpe, Samuel Parker, Florence M.Trusler, George
W. Fray, Ben Hatch, Kathleen Foreman, Mary T. O’Rourke, George Kearns, James
T. Gray, Henry J. Barlow, Francis IT. Redrup, Frederick C. Finch, Frederick H.
Edens, James Knapp, Hector J. Wade. Herbert Cheeseman, Margaret Barry,
Dorothy G. Jackson, Ernest J. Budd, James C. Pritchard, Percy W. Turner,
George Dunaway, William Sharman, Elizabeth Thomas, Margaret Francey,
B. M. L. Smith, Nora O'Rourke, Agnes M. A. Matthews, Charles Ray, Agnes
Bourke, Gwendoline Newman.

Fountains (Temporary ).—Hilda F. Pipe, Winifred Pointer, Florence Aldred,
Dora M. Eggleton, Rose Waters, Margaret Thompson, Ivy Darbin, Clara R.
Lusher, Madeline A. Bowra, Gladys L. A. Lewis, Marguerite Carey, Ena Davies,
Frank Bowers, Joseph M. Simcox, William Bass, Jane A. Weller, Hilda Passmore,
Jane C. Lawrence, Winifred D. Medcraft, Dorothy Deane, Lily Waters, Florence
Willerton, Rose Small.

Bailbrock House. —Florence Pick.

Barn-mood. —Hilda May Compton, Dorothy Minett, Elsie F. Shelswell, Florence
A. Hart, James H. Day, James Dance, Frank H. Winkworth, Wm. Braithwaite,
Wm. Charles Hancock, Frank J. Clissold, Charles J. Virgo, Thomas Harris, Harry
A. Huggins.

Bethlem. —Bridie Hunt, Doris Daisy Jupp, Edith Mary Trigg, Daisy Burch,
Marie R. Fletcher, Mary Christie.

Brislington House. —Emily N. Case, Elsie M. Coles.

Bootham Park .—Janet Guthrie, Tacy Newbound, Harry Rawson, Oscar Shaw,
Michael O’Rourke, John Wm. Dobson.

Camberwell House. —Dorothy E. Cullum, Annie R. Smith, Emily Hodgkins.

Cheadlc Royal. —Lucy Nash, James Loftus, Walter Brough, Frank Wood.

Coton Hill. —Doris Greenfield, Elsie Howard, Charity D. Derry, Mary E.
Jones.

Coppice, Notts. —Patrick J. Gough, Frederick J. Woolnough, Arthur E. Elsworth,
Jessie Waterfield.

Middleton Hall. —Louie Leonnard.

Moorcroft. —Lilian E. Chetwin, Albert G. Guley.

Peckham House. —Florence G. Pooley, Mary P. Brennan, Ada Pearson, Ada P.
Diss.

Retreat. —Edith M. Bcrtinshaw, Annie M. Evans, Janet L. Glendinnings, Norah
Mann, Hilda F. Priestley, David I. Roberts, Fred Wilson.

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514 NOTES AND NEWS. [Oct.,

St. Andrews. —Bridget M. Fennesy, Brigid McNally, Lucy Briggs, Annie Byrne,
Mary Shanahan, Thomas A. Rickard, Harold G. Bartlett, Archibald J. Mills,
Ernest Irving, Joseph Faulkner, Thomas P. Hawker, Harry B. Furn.

Ticehurst. —Annie Gibbons, Annie M. Kendrick, Beatrice A. Webster.

Holloway Sanatorium. —Charles W. Barkham, George F. Worth, Charles
William Dyos, Philip H. Pike, Harry Evans, Gwendoline M. Lowe, Ivy E. Fox,
Clara Lovelock, Rose A. M. Jeffs.

Warneford. —Gladys G. Phipps, Florence M. Jones, Dorothy M. Philps.

Aberdeen Royal. —Ann E. M. Souter, Isabella Clark, Lizzie Guthrie, Margaret
Ross, Gertrude Paterson, Christina Cordiner, Isabella Horne, Clara Mitchell,
Maggie Alexander, Jean Brigid Ord.

Aberdeen District. —James Gerrie, William Grant, William Warrick Burnett,
John Ledingham, George R. Burnett, Jeannie Matthew, Elizabeth Park, Mabel
Watson Roy, Margaret Ellen Grant.

Ayr District. —Margaret Love, Lily W. Beavis, Hannah Campbell, Elizabeth
H. M. Happle, James Paterson, Robert F. Geddes.

Argyle and Bute. —Jessie Macdonald, Isabella McConnachie, Christina Mac¬
donald, Mary McLachlan, Mary McGilp Ferguson, Mary McDonald, Annie E.
McPhee, Isabella McMillan.

Banff. —Elizabeth Munro, Edward Donald, John Gardiner.

Crichton Royal. —Margaret Stewart, Agnes Robertson, Joanna C. Duncan,
Elizabeth K. G. Mowbray, Margaret M. Drummond, Elsie M. Scott, Ethel
McSherry, Elizabeth M. Handley.

Edinburgh Royal. —Joan Newstead, Janette K. McCargo, Mary Lucas.

Craig House. —Mary McGovern, Johan Sinclair, Harry Jackson, Nannie Tait,
Elsie D. Mackenzie, Christina Henderson, Mollie Moran.

Elgin. —Charles Robertson, John McLaren.

East Lothian. —Helen Cosgrove, Mary G. McDonald.

Fife and Kinross. —Lily Fraser, Mary Fleming, James G. McKay, John H.
Grome, Margaret Brown.

Gartnavel. —Christina McKenzie, Christina Morrison, Ada Mason, Mary Johnson,
Veronica Eardley, Elizabeth Drysdale.

Gartloch. —Neil McKenzie, Emma Duffy, Annie Nicholson, Mary J. R. Devlin,
Jean Clarke, Elizabeth Carroll, Jessie Helen Keir, Isabella M. Wilkie, Kennethina
Mackay, Rachael McCaskill, Grace Tennant, Edward Hannan, John Kilgore, Daniel
McKay, Harry Atkins, John Kirkwood, William McManus.

Woodilee. —Patrick McTernan, Marjory Whyte, Isabella Baigrie, Rebecca Bain,
Jean Brandie, James Cooper, Thomas McAuslan, Edward Moy, Murdoch Cameron,
Andrew Orr, David M. Stirling, John Philp, Norman Corbett, Sara Rodgers,
James Stuart, Margaret P. Cameron, Sarah Upton, Janie Kerr Nelson, Agnes
Jarvie, Rose O'Neill, Rachael Shanhan, Catherine Docherty, Helen D. Watt,
Catherine McDougall, Mary Galloway, Mary Wilson.

Hawkhead. —Malcolm McCormick, John Macdonald, James Rae, Thomasena
Begg, Edith Johnson, Flora Macdonald, Mary Procter.

Inverness. —Jane Chisholm, Sussanna Fridge, Jessie F. Parker, Madeline Fridge,
Catherine Fraser, Elizabeth Leith, Florence Macdonell, Lily Ellen Chisholm,
Annabella Mutch, Duncan Munro.

Kirklands. —Richard Gibson, John McLaglan, Isabella Baird, Mary Magee,
Jessie Hutchinson, Isabella Grant.

Lanark. —Elizabeth E. Young, Margaret Winning, John Campbell, Donald
Graham, David Henry Jackson, Robert Leggate.

Melrose. —Hannah M. Smythe, Margaret Cameron.

Montrose. —Flora A. Campbell, Jean Kerr McFarlane, Elizabeth Mackinnon,
Elizabeth M. Milne, Gladys M. Mortloch, Jessie Patterson, Mary C. Samuel,
Edward David McKay.

Murray. —Alyce S. Middleton, Violet Jack, Marion Anderson, Joan Grant,
Mary Aitken.

Perth. — Helen J. Brodie, Annie M. Fyfe, Helen Sutherland, Elizabeth Fairbain,
Christina Macdonald.

Riccartsbar. —Duncan Campbell, Thomas Matthew, James Cruickshank.

Scottish National. —Mary Pugh, Margaret R. Hutton, Mary W. Dolgetty,
Janet Bryce.

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NOTES AND NEWS.

515

Larbert. —George S. Cameron, Christina Scrimgeour, Mary M. Clapperton,
Delia Bradley, Barbara Whyte.

Stoneyettes. —Annie Thomason, Jean Pollock, Brigid Kane, Isobel A. Beattie,
James Inglis.

Armagh. —John Rice, Maggie Rooney, Emma Neville, Owen Murphy, John
Devine, Susan Carroll.

Richmond. —Annie Foley, Mary C. Reid, Catherine Dunne, James Costello,
Joseph Kerrigan, John O’Toole.

Monaghan. —Elizabeth Sheridan, Thomas Simpson, Marcus Maxwell, Philip
Murtha, Patrick McQuillan, Joseph McElroy.

Omagh. —Thomas Coyle, Patrick Fullerton, Michael Hunt, William S. Moore,
Margaret Clarke, Maggie Devlin, Sarah Jane Guy, Eileen McAleer, Mary A.
McEnnill, Mary McHugh, Mary Agnes Rodgers, Rose Sharkey, Letitia A.
Thompson.

St. Patrick's Hospital. —Sarah Branigan, Francis Callaghan, Lillian Quin, Maud
Williams.

Belfast. —William J. Flanaghan, Cathleen Magee, Mary McLaughlin, Edith
McCullough, Annie Clements, Maud Moffatt, Helena Fuery, Teresa Murray,
Agnes Young, Elsie Nesbitt, Johanna D’Arcy, Adina Martin, Martha E. Rowland,
Minnie Stoops, Alexander Murray, John McCrudden.

Portrane. —Thomas Devally, Peter Higgins, James Carney, Mary Feeley,
Margaret M. Fitzpatrick, Teresa Fitzpatrick, Saidie Davey, Mary Coyne, Mary J.
Eaves, Bridget O’Callaghan.

Ballinasloe. —Thomas Coleman, Peter Dooley, Mary Anne Dolan, Annie
Keatings, Katie Guinnessey.

Bethlem. —Thomas W. Channel), Stanley G. Gayland, Joseph H. Wheeler.
Peckham. —Walter R. Wood, J. O'Connell.

West Ham. —Ethel F. Baker, Rose O’Kill, Cecilia D. Barber, William J.
Perkins, Lewis John Hazeldene, Herbert F. Everett, James King, George
Frederick Ball, Herman Jones, William G. Golding.

Hants County. —Alexander Walker, Frederick Jones, Samuel Henry Giles,
Owen W. Pharoah, Bertram R. Jelley, May Bocher, Lilian A. Banting.

Warwick County. —Teresa Dunne, G. S. Fowler, Bridie Dunne, M. Rainbow,
Percy Ashbourne, James W. H. Mason, John Frederick Yardley, Ernest A.
Prestwich.

Federated Malay States. —Cheng Yean Ooi, T. Nagaretuam Ponnoiah.
Pietermaritsburg. —Dora E. Shuttleworth, E. M. V. Biggs, A. W. Taylor.
Pretoria. —M. J. Mandy, A. M. E. Fourie, F. Statham, C. F. Marais, F. Nixon.
Crahamstovin. — A. M. Penn, H. M. Scholte, C. J. Van Eyssen, L. M. Kent.
Valkenberg. —J. A. Burger, H. S. Lotter, S. F. Steenekamp, M. S. J. Van
Heerden, C. M. Van Jaarsveld, J. Van Zyl.

Fort Beaufort. —E. C. Yorke, E. V. Bezuidenhout.

Bloemfontein. —M. M. Coetzer, T. G. Victor.

Final Examination, Mav, 1920.

List of Successful Candidates.

Three Counties, Hitchen. —John Henry Buckley, - Albion Clifford, Basil L. Prior.
Fulbourne. —James P. O’Hirkey, Ruth Handshaw.

Chester County. —Elsie Littler, *Sidney Bretherton, Martha H. Jones, Evelyn
Bailey, Nellie Hiron.

Macclesfield. —Annie James, Martha Annie Ford, Edith Beach.

Corn-wall. —Lily Bassett, Mary Kent, Lottie Harris.

Denbigh. —Annie Lewis, John Blythyn.

Devon County. —Moses Dorey, ’Harry Channing, Harry Winson.

Dorset County. — Horace James Fox, Mariannie Mclnerney, William James.
Hunt, Bertha Feltham.

Durham. —William Ed. Dickinson, Robert Cunningham, Tom Hunter Wetherill.
Severalls. —Walter Arthur Comer, Sydney Herbert Trower, ^Alfred Radley,
Alfred James, Evelyn Maud Denley, Rosanna McNulty, Agnes Marshall Duncan,
Julia Mary Wiles, Bertha Jones, Ethel Taylor, Gwladys Morgan, Frances J.
Thompson, Edith M. Calver, Dora Wilson.

LX VI. 34

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516

NOTES AND NEWS.

[Oct.,

Digitized b:

Hill End. —Percy Sims.

Glamorgan. —Lloyd Jones, Margaret Davies, Elizabeth Jane Jones, Margaret
Evans, Thomas George Hand, Joseph Carr.

Brentwood. — Eva Miriam Barker.

Isle of Wight. —Grace Baxter.

Kent County. —Robert A. Brooker.

City of London. —’Alfred William Fletcher, Helen A. Inglis.

L.C.C.,Banstead. —Florence Maria Marley, Isabella M. Thomson, Violet Winifred
Cownden, Annie E. Clarke, ’Julia May Hurley, "Marcelle Walters, Annie McBrien,
Catherine O'Shea, Bridget T. Ryan, Ellen E. Duncombe, Edith F. Dean.

L.C.C., Bexley. —Samuel T. Bowden, Ernest D. Gough, Sidney Seaman, William
Henry Bishop, Mabel Gladys Shove, Violet A. Spratley, Edith Florence Duce,
Josephine M. Ripley, Margaret Lucey.

L.C.C., Cane Hill. —’William Thomas Mollard, Ernest Edward Boniface, Thomas
Walter Page, *Percival F. Russell, Albert Edward De Rose, Georgina M. Rumble,
Dorothy M. Drake, Agnes Marie Purdy, Mildred Ellen Sims, Myra Johns, Fanny
E. Heselton.

L.C.C., Claybury. —Dorothy E. Slater, Elizabeth Reddin, Alice McGillicuddy,
Elizabeth Butcher, Herbert E. Nicholls, Thomas J. Banks, George E. Matthews,
Henry J. James, Frederick E. King, Alfred P. Pavely, Denis Callaghan, John V.
Jeanes, Frederick G. Cadley.

L.C.C., Colnev Hatch. —Annie L. Downs, Emily Maguire, Vida H. Webber, Rose
E. Bradshaw, Eva M. Childs.

L.C.C., Horton. —Elizabeth Jones, Alfred E. Lacey, Edwin George Bessant,
H. F. W. Miles, Thomas H. M. Blench, Herbert Winter, George Edward Briggs,
Harvey Clarke.

L.C.C., Hanwell. —Margaret Morris, Daisy A. Partridge, ’Lillian May Bond,
Florence Keen, Margaret A. Lovell, Jessie L. Winsor, Leonard Kidd, Reuben
Plumridge, Albert James Webb, "Alfred C. Green, Doris Granger, Jennie Jones,
Amy Frost, Ellen S. Clements, Mary E. Dickens.

L.C.C., Long Grove. —"May Geddes Burns, Eva Mary Dufferin, Elizabeth Miles,
Gwenlillian Williams, Lillie Stevenson, Thomas A. Lipyeat, Frederick E. Banyard,
Bob Acres, William T. Warren, William H. Christian, Ephraim L. Willsher.

L.C.C., Manor. —Gertrude F. Welton, Dorothy May Cross, Alice Maud
Demont.

Springfield. —Robert George Gover, Percy M. Frewer, ’Thomas F. Wood-
gate, Edith Mary Germany.

Napsbury. —Annie Parkinson, Thomas Saunders.

Notts County. —Ruth Bullamore, George Higgs, Charles Wortley.

Cheddleton. —Evelyn M. Bradshaw, Jennie Mary Cassidy.

Brookwood. —Beatrice F. Gardner, Lucy H. Sherry.

Netherne. — Ethel Wallcroft, Harriett Bastin, Bridget O'Halloran.

Hellingly. —Edith Francis, Mabel F. Grover, Lillian Thompson, Doris L. Lucia,
Albert Grover, Percival V. Godley, Frederick J. Glover, Ernest H. Spencer,
Arthur W. Cheal.

West Sussex. —Joseph Pennicott, ’Arthur W. Riley, William Wilds, Dorothy E.
Farley.

Beverley. —William Fletcher, ’Herbert Stephenson, Mary E. Ramshaw.

Barnsley Hall. —Randolph Stephens, "Charles F. Rice, Jonas J. Wakeman,
James W. Durant, Emily Kate Newman, Emily S. D. Rawlings, Helena A. M.
Brown, George A. Kings.

Salop. —Elsie M. Bray.

Menston. —Violet Hare, ’Cissie Phillips, Mabel Turnill, Bertha Wade.

Winson Green. —Edward Lloyd, Nathaniel Clayton.

Haywards Heath. —Ellen H. Smith, John T. W. Weller, Ernest G. Fuller,
Edward A. Hammond, Edith Iron, "Grace A. Lane, Constance L. Thomson,
Rose J. Wingrove, Frances Phillips, Minnie McGuiness.

Canterbury. —Bessie Newing, Beatrice May Wood.

Derby Borough. —Frederick Ball, Charles Henry Hester.

Cardiff. —Euphemia McLaren, Albert Moate, Joseph Hassell, "Gladys May
Radcliffe, Albert F. Park.

Gateshead. —Annie Murray.

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NOTES AND NEWS.

5 1 7

Hull City. —John W. Ellerher, John Hemingway, Bernard C. Wilson, Eveline
Brown, Marjory Hardie, Rosemary Nicholson, ’Elsie Robinson, Ethel Sonley.

Leicester Borough. —*Frank Laundon, *Kate Cocks, Millicent Townley.

Notts City. —Elizabeth MacGuinness, Annie Clements, Maud Clements, Hilda
Pearce.

Portsmouth. —Margaret Boobyer, *Hilda Larkham.

Sunderland.— Andrew Collins, William Woods, Annie Auchterlonie, Hannah
Shillaw, Edith Mary Wanless.

York City. —Montague Francis Smith, Frances May Swift, Alice Emily Granger.

Bailbrook House. —Ethel Ada Newth.

Camberwell House. — Mary S. Roberts, Marion G. Green, Arabella S. Prince,
Mary Elizabeth Welton, Maureen M. McGuinness.

Holloway Sanatorium. —Ethel Chesterfield, Celia J. Orme, George Warren,
Frank Raymond Coomber.

St. Andrews. —Arthur Easton, Hugh Owens, Edwin Walter Isom, *Roland
Waters, Charles Miles, Mark Johnson.

Ticehurst. — Florence Tomlin.

Bootham Park. —Sarah Hutchinson, Elizabeth Jane Steward, Henry Kay.

Peckham House. —George Henry Cass, Annie Packer, Winifred Ward, William
Stephen Griffin.

Retreat. —George Frederick Goodwin, Mary Grade, Ada Jeanette Pettinger,
Evelyn Marion Torr, Joseph William Traynor, William Wood Weatherill.

Caterham. —Harold William Woodward, Edith Beatrice Dobberson.

Warneford, Oxford. —Gladys Irene Harris, Henrietta Davies.

Bethlem. — Marion Florence Mullenger, Walter Salway Mayne.

New Saughton Hall. —Margaret Shaw.

Scaleboro’ Park. — Lillian Mary Mavin.

Aberdeen Royal. — Fanny Ross.

Aberdeen District. —Jeannie Beedie, Alexander B. M. Milton, Maggie Johnston,
Elizabeth Helen Gordan.

Ayr. —Annie Fulton Goldie, Agnes Wilson Blackwood, Rosina M. McCullock,
Frances Jeffery McLaren, Agnes Goldie Sim, Christina Littlejohn, Agnes Herbert,
John Mclnnes.

Argyle and Bute. —Marion McDonald.

Banff. —Jane Watson.

Crichton Royal. —Arthur Ernest Rae, Elizabeth Jane Moodie, Peggie MacRae,
Jeannie Raffin, Jessie Cairns Muircroft, Maggie Ann Buchan, Mary Williamson
Brand.

Edinburgh Royal. —Elizabeth Margaret Gray, Agnes Rutherford Mawer.

Craig House. —Helen Lawson Pryde, Jessie Rae Nicol.

Elgin. —Margaret Begg Hendry.

Fife and Kinross. —William Anderson, Jean Oliver Beattie, Isabella Nuthall,
’Christina Nuthall.

Cartnavel. —Isabella Russell, Annie O’Donnell, Annie McMillan Annie Mac¬
donald, Catherine MacArthur, Robina Brown, Emily Bailie.

Gartloch. —Joan Fraser, ’Annie Wedderburn Diack, ’Helen Menzics Deas,
Williamena Morrison, Christina Cruickshanks, Grace McLellan, William Watson,
Hughie Mackay.

Woodilee. —Lily William, Mary Macdonald, Katherine O’Connell, Patiick Keogh,
•George English, William Dunsmure, Jessie Smith Angus, Helen Mathieson,
Minnie McGeean, Jane Higgins, Agnes Maitland.

Hawkhead .—Mary Barclay, *Margaret MacBean, ’Margaret Robinson, Robina
Thomson, *Margaret Macdonald.

Inverness. —William Campbell, Isabella McDonald.

Kirkland. —Margaret Galloway Brown.

Lanark. —Agnes R. Hutchon, Margaret Mullin.

Montrose. —Mary Isabella Duthie, ’Ella E. C. Y. Gibson, ’Chrissie Innes.

Murray. —Kate Duff.

Perth District. —Maggie Stewart Balnaves.

Larbert. —Isabella Donnan, Annie Evelyne McCarroll, Janet Kilpatrick, Alexander
Archibald, James Edward.

Armagh. —Peter Rush.

lxvi. 34 §

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5 1 8

NOTES AND NEWS.

[Oct., 1920.

Richmond. —Bridget Williams, Annie Lyons.

Monaghan. —Joseph Cochrane, Thomas A. Maxwell, Robert Williamson.

St. Patrick's. —Rebecca M. Belton.

Portrane. —Henry Falconer, Thomas Browne.

Mullingar. —*James Martin.

Warwick. —Florence Ward, Nellie Williams, Katie Larkin, George Burgess,
Alfred M. Rogers.

Pretoria. —J. C. v. d. Werff, G. Foster, E. Norman.

Grahamstown. —M. M. R. Andrew, J. J. Enslin, *A. L. Tomlinson.

Valkenberg. —T. H. Page, A. S. Pepler, Z. M. Reyneke.

Fort Beaufort. —E. L. Yorke.

* Passed with distinction.

NOTICES OF MEETINGS.

Quarterly Meetings. —November 25th, 1920; February 25th, 1921; May 26th,
1921.

South-Eastern Division. —October 14th, 1920, Three Counties Asylum, Arlesey.
South-Western Division. —October 29th, 1920; April 24th, 1921.

Northern and Midland Division. — October 21st, 1920, The Coppice, Nottingham ;
April 21st, 1921, Gateshead Mental Hospital, Stannington.

Irish Division. —November 4th, 1920, College of Physicians, Dublin; April yth,
1921 ; July 7th, 1921.

APPOINTMENTS.

Johnstone, Miss E., L.R.C.P.&S.Edin., L.R.F.P.&S.Glasg., Assistant Medical
Officer, City Mental Hospital, Leicester.

NOTICE TO CONTRIBUTORS.

Writers are reminded that, according to Lix(a) of the Articles of Association,
*' all papers read at the Annual, General, or Divisional Meetings of the Association
shall be the property of the Association, unless the author shall have previously
obtained the written consent of the Editors to the contrary.”

Papers read at Association Meetings should not, therefore, be published in other
Journals without such sanction having been previously granted.

MEMORANDUM.

The Annual Subscription for Ordinary Members of the Medico-
Psychological Association will be £1 11s. 6d. after December 31st,
1920.

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INDEX TO VOL. LXVI.

Part I.—GENERAL INDEX.

Acidosis, significance of, in certain nervous diseases, 244
Adams, Dr. J. Barfield, obituary, 196

Alcohol, influence of, in the production of hallucinations in general paralysis, 168

Alcoholic inheritance, 266

Alcoholism, chronic, pathogenesis of, 61

„ psycho-pathology of, and some so-called alcoholic psychoses, 233
Antipathy, social fatigues and, 300
Anxiety states occurring at the involutional period, 274
Appointments, 82, 354, 518

Arteriosclerotic psychosis, a typical form of, 304
Asexualisation, notes on, with report on 18 cases, 471
Asylum reports, 314, 476
Atheroma and anoxaemia, 380
Auditors, appointment of, 479
„ report of the, 483

Bedford, Hertford and Huntingdon Asylum, report for 1918, 314
Berlin Institute of the Sexual Sciences, 63
Birmingham Asylum report for 1918,315
Blood urea, nitrogen in katatonia, 61

Board of Control, fourth and fifth annual reports, 1917-1918, 283
Borderland neuroses and psychoses, modified psycho-analysis in, 61
Brighton Borough Asylum Report for 1918, 315

British Medical Association, annual meeting, section of neurology and psychiatry,
450

Bucks County Asylum, report for 1918, 316

Buxton : Annual meeting of the Medico-Psychological Association, 478

Canterbury Borough Asylum, report for 1918, 316
Carmarthen, Cardigan and Pembroke Asylum, report for 1918, 317
Cerebral cortex, functions of the, 392
Classification of industrial applicants, 475
„ proposed new, 58

Clinical notes and news, 438

„ psychiatry, 57, 166, 304, 466
Coencesthopaths, constitutional, 59
Colin, Dr., election of, as an honorary member, 479
Committees, election of, 479
Constitutional coencesthopaths, 59
Correspondence, 186, 341

„ re extending the scope and membership of the Medico-Psycho¬

logical Association, 498
Convalescent fund for mental nurses, 352
Cortex in disease, 402

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520 INDEX.

Council and officers, election of, 479
,, report of the, 480
Cretin imbeciles, 273

Crichton-Browne, Sir James, and the Maudsley lecture, 80
Crime and madness, modern views of responsibility, 343
Criminal as a patient, 310

„ courts, mental disorder and defect seen in the, 422
Criminology, psychiatric arms in the field of, 310
Croydon Borough Asylum, report for 1918, 317
Cyto-architectonic picture, 304

Defectives, care of, 81
Degeneration, stigmata of, 266
Dementia prsecox in twins, 466
„ „ nosology of, 282

,, ,, relation between the reproductive organs and, 414

,, „ „ of tuberculosis to, 171

Depression, state of, 376
Derby County Asylum, report for 1918, 319
Dinner, annual, at Buxton, 497
Diplomas in psychological medicine, 14, 20, 504
Dorset County Asylum, report for 1918, 320
Drapes, Dr. Thomas, obituary, 66, 83

Dream-state due to acute exhaustion, with psycho-analytic note, 60
Dreams and primitive culture, 158
Dunn, Dr. Edwin Lindsay, obituary, 195

Eager, Dr. Wilson, obituary, 352
Editors, report of the, 481
Educational committee, report of the, 483
„ notes, 506
Egypt, lunacy in, 1918, 173
Election of members, 68, 334, 491
Emotion, exaltive, 378
„ nature of an, 372
Emotions, physiology of the, 363
Endocrine considerations, mental cases with, 23
Enterostasis, 356
Epilepsy, pituitary gland in, 310

„ syphilis as an astiological factor in, 165
Epileptic children, sane, care of, 469
Epitome of current literature, 50, 162, 300, 464
Essex County Asylum, Brentford, report for 1918, 322
Examination papers for the certificate in psychological medicine, 508
„ „ „ nursing certificate, 508

Examinations, nursing, list of successful candidates, 509

„ oral nursing, payment of the coadjutors of the, 490

Exeter City Asylum, report for 1918, 323
Exhaustion, dream-state due to, 60

Fearnsides, Dr., obituary, 67

Funds, motion involving the expenditure of, 491

Garden party at Buxton, 496
General paralysis among the Jews, 57
„ „ and traumatism, 305

„ „ treatment of, 46

Glamorgan Asylum Report for 1918, 324

Hallucinations, influence of alcohol in the production of, 168
Hallucinatory, chronic, psychosis, discussion on, 178
„ psychosis, chronic, 99

Handbook Committee, travelling expense of the, 489

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INDEX.

521

Hants County Asylum report for 1918, 325

Head injuries in relation to the psychoses and psycho-neuroses, 111
Hyperglycemia in mental disorders, 304

Hypermnesia, retro-active, and other emotional effects on memory, 303
Hypnosis and suggestion as an aid to treatment, 76

Incipient mental disorder, correspondence (Dr. Goodall), 502
„ „ disease, treatment of, 338

,, „ disorder, treatment of (Ministry of Health Bill), 500

Industrial applicants, classification of, 475

,, efficiency, psychiatry as an aid to, 171
Industry, psychiatric point of view in, 474
Infections, relation of, to mental diseases, 227
Influenza, psychoses and, 306
Insanity, pathology of, 61, 170

,, treatment of, 61, 169, 307, 469
„ tuberculosis and, 81

Involutional period, anxiety states occurring at the, 274
Irish Division meetings, 74, 337, 497

„ „ special meeting re Ministry of Health and the Irish Public Health

Council, 182

,, Medical Service and its relation to the Ministry of Health Act, 75
„ Public Health Council, memorandum to the Chief Secretary from the Irish
Division, 182

Jews, general paralysis among the, 57
Katatonia, blood-urea nitrogen in, 61

Kent County Asylum, Barming Heath, report for 1918, 326
„ „ ,, Chartham Down, report for 1918, 326

Laboratory, small clinical, minimal requirements of a, 492

Lebanon Hospital, report, 1918-19, 172

Library for deaf education, 194

London City Asylum, report for 1918, 327

Lunacy in Egypt, 1918, 178

Luncheon at Buxton, 495

Madness, crime and, modern views of responsibility, 343
Malingering, 168

Maudsley Hospital, psychological medicine, 506

„ Lecture, the first, delivered by Sir James Crichton Browne, 199
,, Hospital lectures, practical courses of instruction, 193
Measurements of cortex depth, 304

Mechanism of involutionary melancholia (Presidential address), 355
Medico-Psychological Association and its finances, 68

„ „ „ seventy-ninth annual meeting held at Buxton,

478

„ „ „ meetings, 64, 175, 478

Meetings, dates of the, 491

Melancholia, involutionary mechanism of (Presidential address), 355
„ posture in, 387

Memory, retro-active hypermnesia and other emotional effects on, 303
Mental cases with endocrine considerations, 23
„ defect, analysis of 200 cases of, 254
,, defects and anomalies of the hard palate, 170
,, disease, incipient, treatment of, 338
„ diseases, diagnosis of, 308

,, disorders and defects seen in the criminal courts, 422
„ „ relation of infections to, 227

,, ,, study and treatment in early stages, 186

„ division of the Welsh Metropolitan Hospital, report, 438

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522

INDEX.

Mental hospital, reports for 1918, 314

„ hospitals, rehabilitation of patients in, 468
„ inefficiency, studies in, 154

,, treatment, early, and the rights of the subject, 341
Mercier, Dr. Charles Arthur, obituary, 1

„ „ ,, ,, note by Sir George Savage, 78

„ „ „ „ „ Dr. H. de M. Alexander, 79

Metropolitan Asylums Board, report for 1918, 476

Ministry of Health Bill and the treatment of incipient mental disorder, 500
,, ,, first annual report (1919-20), 499

„ „ report on deputation to the, 64

Mongolian and cretin imbeciles, 272
Monmouthshire Asylum report for 1918, 328
Myxcedematous psychosis, 469

Nervous mental disorders in soldiers, 467

„ disease, significance of acidosis in, 244

,, system, involuntary, 359

Neurology, 304
Neuropathic inheritance, 264
Neuroses and the psychoses, indentity of the, 88
Neurosis, acute prison, of the anxiety type, 169
Newport Borough Asylum report for 1918, 328
Northern and Midland Division meetings, 76, 336
Nosology of dementia prascox, 282
Notes and news, 64, 175, 478, 518
Notices by Registrar, 198,508
„ of meetings, 198, 353, 578
Nurses’ Handbook, revision of the. 68
,, mental, convalescent fund for, 352
,, Registration Act, 1919, 190
„ „ (Scotland) Act, 1919, 348

Nursing, General Council, England, 347

Obituary.—Adams, Dr. J. Barfield, 196
Drapes, Dr. T., 66
Dunn, Dr. Edwin Lindsay, 195
Eager, Dr. Wilson, 352
Fearnsides, Dr., 67
Mercier, Dr. C. A., 1, 66
Southard, Dr. Elmer E., 197
Tuke, Dr. John Batty, 507
Occasional notes, 152, 282, 450
Officers and council, election of, 479

Palate, hard, anomalies of the, and mental defects, 170
Parliamentary committee, report of the, 483
„ news, 345

Pathogenesis of chronic alcoholism, 61

Pathology of insanity, 61, 170

Penal system in Scotland, reform of the, 142

Pituitary gland in epilepsy, 310

Portsmouth Borough Asylum, report for 191S, 329

Post-graduate study, report of the sub-committee on, 483

Presidential address, Dr. W. F. Menzies, “ Mechanism of Involuntary Melancholia,”

355

Prisoners in the psychopathic laboratory at the India State prison, survey of
2,500,310

Prisons, psychiatric annexes for abnormal mental cases in, 471
Psychiatric annexes and special therapeutic sections for abnormal cases in prisons,
47 ».

,, arms in the field of criminology, 310

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INDEX.

523

Psychiatry as an aid to industrial efficiency, 171
„ clinical, 166, 304

„ need for schools of, discussion on, 69
» progress of, in England, 152

„ reproach of, in England, 189

„ the need of schools for, 10

Psycho-analysis, modified, in borderland, neuroses and psychoses, 61
Psychological medicine, diploma in, and course of lectures, 193
,, ,, diplomas in, 14, 20, 504

Psychology of the normal woman in relation to her crimes and passions, 162
Psycho-neuroses of war, 131
Psycho-pathology, 56, 464

,, of alcoholism and some so-called alcoholic psychoses, 233

Psychoses and influenza, 306

„ and psycho-neuroses, hospital treatment of, 504
,, ,, head injuries in relation to, ill

,, and the neuroses, identity of the, 88

Psychosis, arteriosclerotic, a typical form of, 304
„ chronic hallucinatory, discussion on, 178

,, hallucinatory, chronic, 99

,, myxcedematous, 469

Psycho-therapy, introduction to, 307
Physiology of the emotions, 363
Pulmonary tuberculosis in a psychiatric hospital, 169

Reception in the town gardens, Buxton, 497
Rehabilitation of patients in mental hospitals, 46S
Report, Lebanon Hospital, 1918-19, 172
„ lunacy in Egypt, 1918, 173
,, of the Auditors, 483

„ of the Council, 480

„ of the Editors, 1919, 481

„ of the Educational Committee, 483

„ of the Parliamentary Committee, 483

,, of the Sub-Committee on Post-graduate Study, 483
„ of the Treasurer, 481

Reports, fourth and fifth annual, of the Board of Control, 1917-1918, 2S3
„ Metropolitan Asylums Board, for 1918, 476
Reproductive organs in dementia prrecox, relation between, 414
Revenue account for 1919, 482

St. Audry’s Hospital (Suffold District Asylum), report for 1918, 477
Salem, witch craze in, 464
Salop County Asylum report for 1918, 329
Sanatoriums for uncertifiable mental cases, 345
Schools of psychiatry, need for discussion on, 69
„ ,, the need of, IO

Scotland, reform of the penal system in, 142

Scottish Division, correspondence with the Board of Control for Scotland, 181
„ „ meetings, 78, 180

Sex expression on a lowered nutritional level, 62
„ morbid psychology of, Shakespeare’s “Othello,” as a study of the, 56
Sexual Sciences, Berlin Institute of the, 63

Shakespeare's "Othello ”<a's a study of morbid psychology of sex, 56

Simulation (malingering) not an adequate diagnosis, 168

Social fatigues and antipathy, 300

Sociology, 62, 171, 310, 471

Soldiers, attempted suicide among, 164

,, nervous and mental disorders in, 467
South-Eastern Division meeting, 335
South-Western Division, 77, 336
Southard, Dr. Elmer E., obituary, 197

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524

INDEX.

Digitize^ b;

Stigmata, character of, 267
Subscription, increase of the, 489

Suffold District Asylum (St. Audry’s Hospital), report for 1918, 477
Suicide, attempted, among soldiers, 164
Suicides, imitative, 80

Sussex, West, County Asylum, report for 1918, 331

Symbol as an energy container, 302

Syphilis as an setiological factor in epilepsy, 165

Temperament, trades unionism and, 474
Toxicomania, study of, 166
Trade unionism and temperament, 474
Traumatism, general paralysis and, 305
Travelling expenses of the Handbook Committee, 489
Treasurer’s report, 481
Treatment of incipient mental disease, 338
,, of insanity, 61
Tuberculosis in insanity, 81
„ inheritance, 270

„ pulmonary, in a psychiatric hospital, 169

„ relation of dementia prxcox to, 171

Tuke, Dr. John Batty, obituary, 507

University of London and psychological medicine, 507

Vote of thanks to the retiring president and officers, 495

War, psychoneuroses of, 131
„ psychoses, diagnosis of, 306

Welsh Metropolitan War Hospital, report on the mental division, 1917—1919, 438
Wilts County Asylum, report for 1918, 331

Witch craze in Salem, with reference to some modern witch crazes, 464
Woman, normal, psychology of the, 162
Worcester County and City Asylum, report for 1918, 332
Word-association, studies in, 159

Yorkshire, West Riding Asylum, report for 1918, 330

Part II.—ORIGINAL ARTICLES.

Bond, C. Hubert, the need for schools of psychiatry, 10
Browne, Sir James Crichton, the first Maudsley lecture, 199
Dawson, Dr. W. R., obituary notice of Dr. Thomas Drapes, 83
Donkin, H. Bryan, obituary notice of Charles Arthur Mercier, 1
Eager, Dr. Richard, head injuries in relation to the psychoses and psycho-neuroses,
111

East, Dr. W. Norwood, some cases of mental disorder and defect seen in the
criminal courts, 422

Goodall, Dr. Edwin, hospital treatment of the psychoses and psycho-neuroses, 502
Henderson, Dr. D. K., anxiety states occurring at the involutional period, 274
Jeffrey, Dr. George Rutherford, notes on three cases showing the value of hypnosis

as an aid to treatment, 76

„ „ some points in connection with the psycho-neuroses

of war, 131

Macpherson, Dr. John, identity of the psychoses and the neuroses, 88
Matsumoto, Dr. T., study of the relation between the reproductive organs and
dementia prxcox, with an introduction by Sir F. W. Mott, 414
Menzies, Dr. W. F., mechanism of involuntary melancholia: presidential address,
1920, 355

Middlemiss, J. E., analysis of 200 cases of mental defect, 254

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INDEX.

525

Monrad-Krohn, G. H., regarding the treatment of general paralysis, 46
Nolan, Dr. M. J., introduction to a discussion upon the Irish Asylum Service and
its relation to the Ministry of Health Act, 75
Prior, Guy P. W., some mental cases with endocrine considerations, with a report
on microscopical findings by S. E. Jones, 23
Read, Dr. C. Stanford, psycho-pathology of alcoholism and some so-called alcoholic
psychoses, 233

Robertson, Dr. W. Ford, relation of infections to mental disorders, 227
Shaw, Dr. B. H., significance of acidosis in certain mental disorders, 244
„ James E., reform of the penal system in Scotland, 142
Steen, Dr. Robert Hunter, chronic hallucinatory psychosis, 99
Thomson, Dr. W. G., minimal requirements for a small clinical laboratory, 492
White, Major E. Barton, abstract of a report on the Mental Division of the
Welsh Metropolitan War Hospital, Whitchurch, Cardiff, September, 1917,
to September, 1919, 438

Part III.—REVIEWS.

Andr^-Thomas, Dr., Psychoth^rapie, 1912, 462

Bolton, Dr. Joseph Shaw, Brain in Health and Disease, 1914, 289
Brown, Haydn, Advanced Suggestion (Neuro-induction), 1918, 56

Cobb, Dr. Ivo Geikie, Manual of Neurasthenics, 296

Drummond, Margaret, The Dawn of Mind, 1918, 161

Fourth and Fifth Annual Reports of the Board of Control, 1917-1918, 283
Freud, S., Sammlung Kleiner Schriften zur Neurosenlehre (Collection of Short
Contributions to the Doctrine of the Neuroses), fourth series, 1918, 453
Frink, Dr. H. W., Morbid Fears and Compulsions: their Psychology and Psycho¬
analytic Treatment, 1918, 54

Hirschfeld, Dr. Magnus, Sexualpathologie, 1917-1918, 156

Jelliffe, Dr. Smith Ely, Diseases of the Nervous System: a Text-book of Neuro¬
logy and Psychiatry, third edition, 1919, 293

Kempf, Dr. Edward J., The Automatic Functions and the Personality, 1918, 155

Mourgue, Dr. Raoul, Etude critique sur l’Evolution des Id£es relative a la Nature
des Hallucination Vraies, 1917, 299

Nonne, Dr. Max, Syphilis and the Nervous System, translated by Dr. Charles Ball,
1916, 51

Read, Dr. C. Stanford, Military Psychiatry in Peace and War, 1920, 458
Rdgis, E., and A. Hesnard, La Psycho-analyse des Neuroses et des Psychoses, 463
Richard, Dr. Esther L., Some Adaptive Difficulties found in School Children
(Mental Hygiene, April, 1920), 459
Rivers, Dr. W. H. R., Dreams and Primitive Culture, 158

Scharlieb, Dr. Mary, How to Enlighten our Children, 55
Smith, Dr. J. Elliot, Shell-shock and its Lessons, 298

Stoddart, Dr. W. H. B., Mind and its Disorders: a Text-book for Students and
Practitioners of Medicine, third edition, 1919, 457
Studies in Word-Association : Experiments in the Diagnosis of Psycho-patho¬
logical Conditions carried out at the Psychiatric Clinic at Zurich, translation
by Dr. M. D. Eder, 159
Sully, James, My Life and Friends, 1918,49

Wohlgemuth, A., D.Sc., Pleasure—Unpleasure: an Experimental Investigation
on the Feeling-elements, British Journal of Psychology, Monograph Supple¬
ment VI, 461

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526

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Part IV.—AUTHORS REFERRED TO IN THE EPITOME.

Barilari, 6r
Barr, Martin W. p 471
Bell, Ju Don, 171
Benon, R., 305
Bianchini, L., 166
Birnbaum, K., 63
Booth, D. S., 165
Boutet, 466
Bowers, Paul E., 310
Brown, Sanger, 467

Case, Irene, 170
Cameron, M. M., 171
Clark, S. N., 468

Ducceschi, 61

Fox, J. Tylor, 469

Glueck, Bernard, 310

H^ger-Gilbert, 471

Hitzenberger, K., 306
Hohman, L. B., 306

Immerman, S. L., 168

Janet, P., 300
Jelliffe, Smith Ely, 302

Kempf, E. J., 58
Koody, F. H., 309

Laignel-Lavastine, 466
Lattes, L., 59, 164
Lombroso, G., 162

McPherson, G. E., 306
McQuade, C. E., 310
Marro, Giovanni, 60
Menninger, Karl, 306
Miles, VV. R., 62

Orton, S. T., 304

ILLUSTRATIONS.

Potts, C. S., 464

Rappleye, W. C., 61
Robertson, George, 307

Sichel, M., 57
Silk, S. A., 169
Southard, E. E., 171, 474
Stanford, R. V., 308
Stearns, A. W., 475
Stratton, H., 303
Sullivan, W. C. 56

Tucker, B. R , 310

Uyematsu, S., 304, 469

Vervaeck, 471

White, W. A., 168

Yawger, N. S., 169

Diagram to illustrate Dr. B. H. Shaw's paper, 249
Portrait of Dr. Charles Arthur Mercier, 1
„ Dr. Thomas Drapes, 83

Photo-microgram to illustrate Dr. Richard Eager's paper, 123, 125
Photo-micrograph to illustrate Dr. Guy Prior’s paper, 25, 28
Tables to illustrate Dr. J. E. Middlemiss's paper, 255, 260, 263
Tables to illustrate Dr. Guy Prior's paper, 44

ADLARD AND SON AND WEST NEWMAN, LTD., !MPR., LONDON AND DORKINO.

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